complaint·November 4, 2025

The investigation revealed the following: Regarding allegation: Staff handled resident in a rough manner. It is alleged resident was thrown by facility staff out of the facility. Interviews with residents revealed 6 out of 6 residents stated staff treat them with respect, have not hurt them, or yell at them. 1 out of the 6 stated there is a staff that is rude but has not verbally or physically assaulted residents. LPA was unable to interview R1, as R1 is no longer at the facility. Interviews with staff revealed there have not been observations or reports of staff mistreating residents. Per administrator there are no warnings or other documents provided to staff to warrant staff mistreated residents within the last 2 years. Facility staff received personal rights training between 4/17/23 – 4/21/23 and most recently on 9/25/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff not meeting resident toileting needs . It is alleged resident had dry feces and was unkept. Interviews with residents revealed 3 out of 6 residents stated staff assist with changing as needed and are prompt. 3 out of 6 residents do not require assistance with incontinence care. Therefore, they didn’t have an answer regarding this question. But they stated they have not observed residents with odors due to incontinence. LPA was unable to interview R1 as R1 is no longer at the facility. Interviews with staff revealed residents are assisted with toileting as needed. Residents with incontinence care are provided assistance every two to four hours depending on their needs. If a resident requires assistance more often staff provide it as needed. Per staff if a resident is in isolation the care continues to be provided as needed while taking proper infection control precautions. Per administrator, on 6/28/23 R1 was found on the floor and had recently had a bowel movement. Per their facility protocol if the resident is in the floor and cannot be move emergency services are called. In this case R1 could not have been changed before going to the hospital as facility’s protocol is not to move the residents until emergency services arrived. In this case R1. LPA was unable to interview R1, as R1 is no longer at the facility. Documents review revealed incident report dated 6/29/23 notes R1 had a fall on 6/28/23 in which emergency services were called. Although the allegation could have happened, per administrator R1 required emergency services at that time. Due to the circumstances, facility staff was unable to provide toileting care during the incident. The allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. (CONTINUED ON LIC 9099C) Regarding allegation: Staff did not provide medical attention to resident in care . It is alleged R1 had skin tears and an eye infection. Interviews with residents revealed 6 out of 6 residents stated that if they needed medical assistance, they would notify Med-tech and they will obtain medical assistance for them. Interviews with staff revealed upon a change in condition or need to send a resident out, the Med-tech and facility’s nurse evaluate the situation and send the resident out to the hospital. Unless the resident refuses, then responsible parties are contact. Documents review revealed per physician’s report dated: 5/17/23 R1 had a medical condition in the right eye. Per Order summary report on 6/20/23 R1 was prescribed treatment for eye condition. Physician’s fax report dated: 6/24/23 notes R1 had a fall and sustain a skin tear which was treated by staff and physician was notified. Although R1 was observed with skin tears and an eye infection per facility records, R1 received treatment for both. Therefore the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Kelly Best Health and Wellness Director an a copy of this report was provided.