complaint·January 7, 2026

LPA conducted an interview with R1 who reported the following information. Sometimes they avoid wearing lower-body garments due to using a catheter. However, they have the capacity to communicate their needs to facility staff and request dressing assistance to wear lower-body garments and weather appropriate clothing. R1 was unable to recall any incident on 12/23/2025 related to the allegation. However, they reported facility staff provide dressing assistance each time they request it. R1 informed LPA where their lower-body garments are stored in their bedroom. LPA then toured R1’s bedroom and observed lower-body garments including several pants stored inside a dresser drawer and in hangars in the closet. Three (3) staff were identified to be present on the incident date and time. However, one (1) staff was unable to provide relevant information due to being in a different area of the facility during the alleged incident. LPA was unable to make contact with the second staff for an interview. LPA conducted an interview with the third staff noted to be present on the incident date and time who reported the following information. On 12/23/2025, R1 was transported to their medical appointment by a transportation service provided though their health insurance program. This staff was unable to recall incident details from 12/23/2025 surrounding the allegation. However, they reported there have been multiple instances in which the transportation service for R1 and other residents failed to inform facility staff of scheduled pick-ups at the facility. This staff reported on one (1) occasion, the transportation service for R1 arrived at the facility at 6:00 a.m. without prior notice and provided facility staff only five (5) minutes to prepare the resident before departure to avoid missing their medical appointment, which was insufficient preparation time. This staff reported facility staff make sure residents are clean, groomed, eat, and are appropriately dressed for the weather prior to leaving the facility for an outing. Administrator was also interviewed and corroborated the information provided by this staff and R1. He forwarded LPA an email dated 01/05/2026 that he sent to R1’s medical provider reporting transportation arrived for a resident without prior notice. In the email, administrator also requested the medical provider share the schedule for any future appointments in advance so the facility can ensure the resident is prepared on time. LPA made contact with the reporting party who was unable to provide additional information regarding R1’s transportation services to their medical appointment on 12/23/2025. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to administrator. Note - LPA was offsite from 12:00 p.m. to 12:30 p.m.