complaint·March 20, 2026

LPA conducted an interview with Staff #1 (S1) who stated that all residents have been provided with three (3) meals a day and plenty of snacks. S1 stated that R1’s records were not available due to expiration of record retention periods. LPA conducted interviews with three (3) residents, all of whom stated that they have had no issues with food services. The Department’s investigation did not provide enough information to corroborate the allegation that staff did not provide adequate nutrition to resident, resulting in resident’s death. This allegation is unsubstantiated. It was alleged that resident developed a pressure injury due to staff neglect. Information received indicated that R1’s pressure injury became so much worse that wound care personnel advised that there was nothing they could do. LPA’s records review revealed that R1 had pressure injury already before R1 was admitted to the facility. LPA conducted an interview with S1 who stated that all residents receive one (1) to two (2) hour check. S1 stated that R1 arrived at the facility with a bruise on their elbow, but R1 did not have pressure injuries. LPA’s attempts to contact R1’s relevant party and hospice agency were unsuccessful due to their non-responsiveness. The Department’s investigation did not provide enough information to corroborate the allegation that resident developed a pressure injury due to staff neglect. Based on records review and interviews conducted, this allegation is unsubstantiated. It was alleged that staff left resident in urine soaked bedding for extended periods of time. LPA’s attempt to contact R1’s relevant party was unsuccessful due to their non-responsiveness. LPA conducted an interview with S1 who stated that all residents receive one (1) to two (2) hour check. The Department’s investigation did not provide enough information to corroborate the allegation that staff left resident in urine soaked bedding for extended periods of time. This allegation is unsubstantiated. It was alleged that staff did not provide resident with adequate fluids. Information received indicated that R1’s hospice nurse informed R1’s relevant party that R1 was severely dehydrated after leaving the facility. LPA’s attempts to contact R1’s relevant party and hospice agency were unsuccessful due to their non-responsiveness. LPA conducted an interview with S1 who stated that all residents have been provided with water and drinks throughout the day. LPA conducted interviews with three (3) residents, all of whom stated that they have had no issues with the facility services. The Department’s investigation did not provide enough information to corroborate the allegation that staff did not provide resident with adequate fluids. This allegation is unsubstantiated. Continued on LIC9099-C.... It was alleged that resident sustained an injury due to staff not providing a safe sleep environment. Information received indicated that R1 sustained head wound from bed rails. LPA’s attempt to contact R1’s relevant party was unsuccessful due to their non-responsiveness. LPA conducted an interview with S1 who stated that staff have provided pillows to residents who use bed rails to avoid any injuries. LPA conducted interviews with three (3) residents, all of whom denied having any injuries from bed rails. The Department’s investigation did not provide enough information to corroborate the allegation that resident sustained an injury due to staff not providing a safe sleep environment. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.