complaint·August 28, 2025

Staff left residents in a soiled diaper for a long period of time. Interviews with residents indicated they feel their incontinence needs are being met by care staff. Interviews with staff indicated that two residents are continent and able to use the restroom with minimal assistance. One resident is incontinent but vocal regarding need to be changed. Interview with Resident R1 indicated that they have no issues with getting assistance with changing after using the restroom. Therefore the allegation staff left residents in a soiled diaper for a long period of time is unfounded. Staff did not properly clean a resident in care. Records reviewed indicated that residents in care were receiving proper care and cleaning which was logged on a daily basis. Records indicated that residents were receiving three or four showers per week unless it was declined by resident. Observations indicated that residents were clean and did not present any odors. Interviews with residents indicated that they feel their hygiene needs are being met by staff. Therefore the allegation staff did not properly clean a resident in care is unfounded. Staff does not ensure that a resident in care is fed. Interviews conducted with Resident R1, R2 and R3 indicated that they are content with the meals being provided at the facility. Interviews with staff indicated that they will assist residents as needed with meals and offer additional options if the food made at that time was not desired or liked. Observations indicated that there is a variety of food at the facility for resident consumption. Therefore the allegation staff does not ensure that a resident in care is fed is unfounded. Staff did not prevent a resident from developing a pressure injury while in care. Interviews with Resident R1 indicated that they stay in bed most of the day but are able to turn themselves and reposition as needed. Interviews with staff and administrator indicated that R1 uses a hoyer lift for transfers out of bed and is able to reposition themselves as needed. Staff assist with changing R1 and have not seen any signs of skin breakdown. Therefore the allegation staff did not prevent a resident from developing a pressure injury while in care is unfounded. ***Report continued on 9099-C2 page Facility is allowing unqualified staff to fill a syringe with medication. Records reviewed indicated that syringes were being filled by outside agency for resident who was on hospice care. Facility documentation indicates when syringes were being filled and given to resident. Interviews conducted with staff and administrator indicated that hospice agency filled all medications for resident. No staff at the facility were in charge of drawing up medications for residents. Therefore the allegation facility is allowing unqualified staff to fill a syringe with medications is unfounded. Staff are smoking inside of the facility. Interviews with staff, administrator and residents all indicated that no individuals smoke within the facility. Observations indicated that there was an ash tray on the back patio of the facility which contained cigarettes. Observations also indicated that there was no odor of smoke within the facility and no physical indications of smoking were seen within the facility. Therefore the allegation staff are smoking inside of the facility is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted. Copy of report was given to facility.