Complaint·April 17, 2026

9099C1-. Allegation: Staff are not following physician's order . T he allegation states that staff are not following resident (R1’s) dietary plan, including serving soft foods and cutting food in small bites, and with serving too many Ensure drinks at a time. The family member stated she signed the care plan which notes (R1) has "aspiration precaution, is at risk due to crackers", the caregiver stated (R1) can swallow Ramen noodles fine, and they are not cutting them; however, resident's Home Health provider said to cut the food in small pieces, and they only do sometimes. The family member stated one time when she visited, (R1) was eating a whole Persimmon, and the facility is "not following orders for aspiration as they gave him ice-cream last Thursday (1/15/2026), and they are supposed to put thickener in it". Additionally, staff are "supposed to cut bite sized sandwich pieces and they gave it to (R1) whole", staff gave (R1)(6) Ensure drinks in one day" due to being "combative". The family member commented that due to (R1) being at risk for sugar, she told staff (R1) should have no more than (3) Ensure drinks each day. On 1/20/26, Staff (S1) confirmed (R1) has "swallowing concerns" and she/staff use "thickener", showing LPA the bottle. Charting notes from 12/9/2025 note there is an order for (3) bottles of Ensure per day, and to continue thickening all liquids. (S1) stated "Yes, I do go over 3 per day because I don't want to be in an argument with him". On 1/20/26, LPA observed all residents to be served a whole sandwich cut diagonally, and (R1) to be eating their soup first. LPA asked (S1) about cutting (R1's) sandwich into bite sized pieces to which (S1) replied "(R1) can eat bites" but agreed to cut the sandwich, adding 'it doesn't have to be bite sized" and commented that (R1) "has improved " and the Speech Therapist did a reassessment and (R1) tends to not chew and just swallow" and stated he hasn't choked in a long time". On 2/23/26, (S1) stated (R1's) diet consists of "regular to soft foods and staff do cut food for him as well as place thickener in all his liquids". Charting notes made on 12/2/2025 and 12/9/2025, document the instructions from Speech Therapists for swallowing safety as: “All foods must be soft and in bite size”. The Administrator stated "staff is cutting it in small pieces- they will puree it if the food is tough to eat, such as a steak, and commented (R1) "always eats in a hurry" and on the discharge paperwork (dated 7/25/25), the diet states to cut it in bite sized pieces. (R1's) Care Plan notes resident is at risk for choking and states resident requires supervised eating/drinking and monitoring, encouragement and/or cueing and resident is prescribed a “mechanical soft diet”. * cont on 9099C-2.. 9099C-2..On 3/26/2026, (S1) confirmed (R1) receives no more than (3) Ensure drinks daily and commented (R’1s) family member brought Glucerna (low sugar) to the facility on Tuesday, (3/24/26), and (R1) is given the Glucerna 3x/day, per previous prescriptions. On the same day (12:00 pm). LPA observed staff and the Administrator reminding (R1) to take small bites during lunch. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Exit interview by phone with the Administrator. Care staff authorized to sign today's report that was provided. 9099A-C-1.. LPA reviewed (2) staff's training records. Documentation showed that both staff had completed the required initial and continuing training requirements for residents with Dementia. The Administrator stated (6) hours of Dementia care included (2) hours in each of the following areas: Recognizing symptoms that may create or aggravate dementia behaviors; Recognizing the effects of medications commonly used to treat dementia symptoms and their impact on the behavior of residents with dementia, and Responsiveness to the general security and supervision of dementia residents. Staff (S1) stated on 1/20/26, that (R1) takes Seroquel and Trazadone which were recently increased (each dosage) and is sleeping better now. (S1) stated (R1) has been physical, has had outbursts since July 2025, and each outburst will normally last 1 hour. On 1/20/26, (S1) stated (R1)was sent out on January 14, 2026, last week, for outbursts and aggression that lasted 18 hours- (from 12 noon until 6 am the following morning) and (R1's) family member enrolled them back in Home Health yesterday, January 19, 2026. Als0o, Seroquel was increased due to OCD (Obsessive Compulsive Disorder) diagnosis- (R1) receives 3x/day- morning, noon and bedtime (which has/is helping). On 2/23/2026, the Administrator was asked about staff training specifically related to handling resident outbursts and responded, "staff know how to handle (R1's) outbursts it is easy to redirect them". The administrator and (S1) confirmed that (R1) would "always put a chair by the closed door" and did this at the prior care home. The administrator indicated she put a lock on (R1's) door, as they requested, following the incident on January 14, 2025 and (R1) "will close and lock the door" but then will unlock the door. Charting notes document (R1) had outbursts on the following days: Jan 12, 2026 (2:00 pm for a “period of continued agitation”), January 1, 2026 (at 12 am and 11 am), and on July 27, 2025 when they were sent to Emergency Room. LPA was not provided with any documentation for specific training related to behaviors caused by diagnoses other than Dementia. LPA recommends staff complete training for behaviors associated to other diagnoses. Based on information obtained, the allegation is found to be UNSUBSTANTIATED- which means that Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. *cont on 9099A-C-2 9099A-C-2... Staff did not ensure that resident received prescribed medication . The allegation states that staff are not making sure that resident (R1) is taking their medication as one of the medication pills were found. The family member stated the caregiver told a friend she found a medication pill on the floor and (R1) will "pretend to take meds". The family member stated that staff says (R1) doesn't sleep, there is a Melatonin prescription, but she was out of town and not able to pick it up, and (R1) takes "Trazadone, PRN, for combativeness and she was present with Home Health was initiated. Staff, (S1) indicated to LPA that (R1) does pretend to take their medications and confirmed she has taken medication training. LPA reminded (S1) that staff must stay when administering medications to ensure each resident actually swallows them. (S1)also indicated she documents when medications are refused. On 1/20/2026. (S1) stated (R1's) family member enrolled them back in Home Health yesterday, 1/19/2026, and there were some medication changes. Seroquel was increased due to OCD (Obsessive Compulsive Disorder) diagnosis to three times daily- morning, noon and bedtime, which has been helping. Physician's orders, 1/14/26, following an Emergency Room visit state: Seroquel (Quetiapine 50 mg) is to now be given (1) tablet (50 mg) twice a day (morning and with lunch) and (5) tablets (250 mg) every night.; stop medications, Fluvoxamine 25 mg (Luvox) and Mirtazapine 15 mg (Remeron), and to continue with Divalproex 500 mg, twice daily; Melatonin ODT 10 mg nightly; Rivastigmine 9.4 mg patch; A new PRN, Trazadone 50 m,was ordered, up to 3 times a day, as needed, for mild agitation and insomnia. On 2/23/2026, (S1) stated (R1) is taking their medications without any issues and there have been no recent changes. Based on information obtained, the a llegation is found to be UNSUBSTANTIATED- which means that Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. *cont on 9099A-C-3... 9099A-C-3... Allegation: Staff do not provide adequate incontinent care. The allegation states that (R1's) "wheelchair was filled with resident poop, there was stool in (R1's) underwear" and staff are "not cleaning" up after (R1's) has a bowel movement. Staff, (S1), stated "(R1) had an accident one time, but on a regular basis, they can clean themself". (S1) explained the one time (R1) had an accident was when they were going to the doctor's office, on 12/8/2025, and the daughter saw a stain on his clothes”. (S1) explained (R1) "hurries and didn't wipe". On 1/20/26, LPA observed (S1) to be asking (R1) if they "wiped and washed their hands" following using the restroom. (S1) stated also on 1/20/26 that (R1) "needs some assistance with toileting" and asserted that (R1's) condition "has improved since moving in", including their blood sugar and blood pressure. The Care Plan (dated 11/10/2025) notes (R1) is “independent” with toileting tasks but is dependent with personal hygiene and requires partial staff physical assistance with completing personal care . The physician's report (7/20/2025) notes (R1) is incontinent x2 and is not able to care for their own toileting needs, and caregiver assistance is required for bathing, dressing, grooming. On 2/23/26, the Administrator stated staff "always checks on (R1)" who will tell staff if they are going to have a bowel movement, so they can assist with cleaning (R1). (S1) asserted "we are always checking on them" and will ask (R1) if they washed their hands, cleaned themself after going to the bathroom once they leave the bathroom. Staff further commented, "we always give a shower to the resident before a medical appointment" and confirmed (R1) must have used the restroom after he received a shower that day (Dec 8, 2025). (S1) stated on 2/23/26, that (R1) is "100% agreeing to taking more showers now than a month ago". LPA did not observe any incontinent odors during the inspection on January 20, 2026, February 23, 2026 March 26, 2026, or on April 17, 2026 when at the facility. The Administrator stated the family member called her and told her about (R1) having some stool residue in their under garments, but it was not certain when this occurred. Photo evidence was not provided to LPA. Based on information obtained, the Department finds the allegation to be UNSUBSTANTIATED- which means that Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview. Care staff authorized to sign today's report that was provided.