Complaint·August 20, 2025

Eight (8) additional residents who were identified to require incontinent care were interviewed. Two (2) of eight (8) residents interviewed denied requiring incontinent care. Three (3) of eight (8) residents interviewed reported receiving incontinent care in a timely manner. However, three (3) of eight (8) residents interviewed reported waiting approximately two (2) to three (3) hours to receive incontinent care from staff after requesting staff's assistance. Based on interviews conducted, this allegation is substantiated. Regarding the allegation, “Staff are not responding to resident's requests for assistance in a timely manner” it was alleged R1’s call light is not working properly so they are forced to call the front desk. LPA reviewed R1’s physician’s report dated 3/13/2025 and the mental condition subsection, “Able to Communicate Needs” is marked “Yes”. R1 was interviewed and reported their call light works properly but facility staff respond approximately forty-five minutes to an hour after R1 activates their call light, which prompts them to call the front desk. Three (3) staff interviewed reported having knowledge R1’s call light works properly. One (1) of three (3) staff interviewed reported they have accidentally activated R1’s call light evidenced by the call light illuminating which required staff to turn it off. A staff interview reported all residents’, including R1’s, call lights have been tested and found to be functioning properly. Nine (9) additional residents were interviewed of which one (1) reported being independent and not using their call light. Four (4) of nine (9) residents interviewed reported activating their call light and receiving timely assistance and waiting up to fifteen minutes. One (1) of nine (9) residents interviewed reported receiving assistance approximately thirty minutes after activating their call light. However, three (3) of nine (9) residents interviewed reported receiving assistance one (1) to three (3) hours after activating their call light for assistance. Administrator, Molly Bowie reported the facility's call light system does not give them the ability to send call log reports or view call light response times. Based on interviews conducted and records reviewed, this allegation is substantiated. Regarding the allegation, “Staff do not ensure that resident is provided with proper incontinence supplies” it was alleged R1’s incontinent supplies are the incorrect size. R1 was interviewed and reported when they moved into the facility, they immediately noticed the briefs provided by the facility were too small because they irritated their skin. Three (3) staff were interviewed and refuted the allegations. Two (2) of three (3) staff interviewed reported although the briefs provided by the facility seemed to be appropriately sized, R1 decided to purchase their preferred brand and size of briefs. One (1) of three (3) staff interviewed reported the brand of briefs the facility uses is sized larger than the standard measurements for that size and accommodates waist sizes greater than R1’s. One (1) of three (3) staff interviewed showed LPA the brand and size of briefs provided to R1, and LPA compared it to the briefs R1 reportedly uses. Based on the brief labels, the briefs R1 uses accommodate waist sizes that are up to twenty-two inches larger than the briefs provided to R1 by the facility. Based on interviews conducted and records reviewed, this allegation is substantiated. An exit interview was conducted and a copy of this report, LIC 9099-D, Confidential Names list (LIC 811) and Appeal Rights were reviewed with Wellness Coordinator, Breanna Jones. Administrator, Molly Bowie called Wellness Coordinator Jones and developed the plan of corrections with LPA.