complaint·December 16, 2025

Allegation #1: Staff do not ensure that the resident’s needs are met. The allegation alleged that the resident, who arrived at the hospital, appeared to be malnourished, unkempt, malodorous, and having fecal matter stuck to him on a soiled diaper and frail. On December 11, 2025, the Licensing Program Analyst (LPA) interviewed the Administrator (A1), who denied the allegation of malnutrition and stated that the facility provides three meals a day along with snacks between meals. A1 emphasized that no residents could be malnourished. The resident in question, Resident #1 (R1), has expressed a desire not to be touched. On the same day, the LPA interviewed five staff members (S1-S5), all of whom also denied the allegation. They confirmed that the facility offers adequate portions of food to all residents and provides an optional menu for those who do not want what is currently being served. It was noted that R1 prefers not to be touched by caregivers, except for one specific staff member, who is making efforts to assist R1 with showering and changing clothes whenever R1 is willing. The LPA further interviewed five additional residents (R2-R6), all of whom stated that their needs are being met. They indicated that staff cannot force them to participate in activities they do not want to engage in because they have rights. Each resident expressed that they had a scheduled shower unless they chose to refuse it. The LPA was unable to interview R1, as R1 no longer resides at the facility and moved out on September 30, 2024. On December 11, the LPA also reviewed R1’s physician report (LIC602A), which showed that R1 was capable of dressing, grooming, and feeding themselves. 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. Allegation #2: Staff did not assist a resident with arranging medical care. The complaint alleged that the resident presented with a left eye mass, causing pain and vision loss. R1 reported experiencing pain for a week, but the facility only sent R1 to the hospital. On December 11, 2025, the LPA interviewed the Administrator (A1), who denied the allegation and stated that the facility had made several appointments for R1 to see R1's primary doctor, but R1's responsible party kept cancelling the doctor appointments. On the same day, the LPA interviewed five staff members, #1-5 (S1-S5), who also denied the allegation. S1 also stated that S1 made several appointments for R1, but R1, the responsible party, cancelled the appointments. Finally, S1 decided to call 911 and sent R1 to the hospital. S1 also stated that the facility tried to have the facility doctor see R1, but R1 refused. The LPA also interviewed five residents #2-6 (R2-R6), all of whom denied the allegation and stated that they had seen the facility doctor twice a month. If they need more urgent care, the facility will call 911. LPA was unable to interview R1 because R1 no longer resides at the facility and moved out on September 30, 2024. 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. No deficiencies cited. An exit interview was conducted. A copy of the report was provided to the Administrator Maria Forkrud.