Complaint·September 4, 2025

On 01/31/2025, LPA Renee Campbell went out to the facility to open the complaint and interviewed 4 residents, and all 4 residents stated they did not have pressure injuries and while observing staff cleaning residents after experiencing incontinence, no sores or wounds were observed but there were areas of redness. On 02/13/2025, 04/21/2025 and 04/22/2025, LPA Holly Williams also went out to the facility to follow-up on the complaint and interviewed both residents and facility staff and there were no residents in care with pressure injuries. On 07/10/2025, LPA Pang Lee visit the facility to follow-up on the allegation and based on interview with, residents, facility staff there were no residents with pressure injuries. Based on records, review R1 has a history of skin breakdown and is placed on hospice. Based on the information, there is not a preponderance of the evidence to substantiate this allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. However, resident 1 (R1) R1 stated that staff sometimes use only one person to assist with transfers. R1’s Needs and Services Plan states two-person assistance with toileting and transfer and according to the medical assessment R1 is bedridden. Moreover, R1 reported that staff rarely use the Hoyer lift and instead one staff will lift them manually by swinging their legs over the bed and transferring them into a wheelchair. According to the facility’s Plan of Operation it states the following: The licensee shall ensure that there is an adequate number of caregivers to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. If any resident requires two staff members to assist or transfer a resident or for any other reason, adequate staff shall be on hand to assist the resident. Based on the information gathered, there is a preponderance of evidence to substantiate the allegation. It was alleged that staff are not ensuring that residents’ rooms are kept clean. During the investigation, Licensing Program Analyst (LPA) conducted interviews with both residents and staff and made direct observations during facility visits. Based on interviews, it was revealed that seven out of ten residents do not have a laundry hamper in their rooms, resulting in residents placing dirty clothes on the floor, often in the corners of their rooms. Additionally, 13 out of 14 staff members confirmed that residents do not have hampers and store dirty clothing on the floor. During LPA Williams' facility visits on February 13, 2025, and April 21, 2025, the following conditions were observed in residents' rooms: · Showers with dirty towels on the floor · Food found on a resident's pillow · Dirty sheets on the shower floor · Closets containing soiled clothing with a strong urine odor · Piles of dirty clothes in corners of rooms · Rooms containing food, urinals, and clothing in the same area CONTINUED LIC 9099-C · Food placed next to urinals · Old food and garbage, including containers and cups, left in the rooms · Soiled towels and sheets on the floor · Cluttered living conditions · Old pizza boxes left in residents’ rooms During another visit conducted by LPA Lee on 07/10/2025, LPA Lee observed two residents’ rooms had a strong incontinence smell. According to the facility’s Plan of Operation, caregiver duties include “maintaining the facility in a neat, safe, and sanitary condition.” Based on the information obtained through interviews and direct observations, there is a preponderance of the evidence to substantiate the allegation that staff are not ensuring residents room are kept clean. It was alleged that staff are not meeting residents’ laundry needs. During the investigation, Licensing Program Analyst (LPA) Holly Williams conducted interviews with residents and staff and made direct observations during multiple facility visits. Of the seven staff members interviewed all seven reported that the facility’s laundry services need improvement. They stated that residents’ clothing is not labeled, which frequently results in laundry being lost or mixed up. Staff also reported that the laundry room doors are often left open and accessible to residents, further increasing the risk of clothing being misplaced. Interviews with residents revealed that 13 out of 14 residents reported missing articles of clothing after the laundry is returned. Additionally, the residents do not have laundry hampers in their rooms to keep their clothing together or labeled, further contributing to laundry mix-ups. During LPA Williams’ visits to the facility on February 13, April 21, and April 22, 2025, the laundry room door was observed to be left open on each occasion. LPA Williams also observed that multiple residents’ rooms did not contain hampers, and dirty clothing was seen placed on the floor in the corners of the rooms not collected for wash. CONTINUED LIC 9099-C Additionally, in one resident’s room, dirty clothes were observed on the floor of the closet, with a strong odor of urine. According to the facility’s Plan of Operation, staff are required to: “Perform resident laundry service to include: 1. Strip bedding and replace. 2. Wash and return all clothes, linen and towels within 24 hours.” Based on staff and resident interviews, as well as direct observations, there is a preponderance of the evidence to substantiate the allegation that the facility is not meeting residents’ laundry needs. Due to this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with administrator Corpus and a copy of the LIC 9099 report, LIC 9099-D, and appeal rights were given to the facility.