Complaint·October 14, 2025

(PAGE 2 0F 4- CONTINUED FROM PAGE 1, LIC 809) An interview with Home Health Representative #1 (HHR1) who visits R1 two times per week also revealed that R1 is clean when HHR1 visits and HHR1 believes that the caregivers are “really, really good” about changing R1’s incontinence briefs. An interview with Staff #1 (S1) also revealed that S1 conducts diaper checks in the evenings and recently, changed R1’s diapers in the evening. There was not enough evidence to support this allegation. It was also alleged that facility staff do not answer the facility phone. A records review revealed that there are two live-in care staff assigned daily to cook, clean and provide caregiving services. During the evening, the care staff rest and are on-call if there are any emergencies, or if residents need assistance. A Department interview with Home Health Representative #1 (HHR1), who visits the facility weekly, revealed that while sometimes care staff do not answer the phone, HHR1 stated that during busy hours from breakfast to dinner, they have observed staff assisting residents with feeding, toileting and other caregiving services. HHR1 stated that they did not believe staff are intentionally not answering the phone and when they have called the facility early, staff answer. An interview with the Responsible Relative (RR) for a resident revealed that they do not have problems having calls answered and stated that they also have the option to call the Licensee/Administrator. An interview with the Licensee/Administrator also revealed that while the facility policy is that staff are required to answer the phone, the priority is to provide caregiving services timely. The Licensee/Administrator provides an alternative contact number for resident representatives to call with any issues and concerns. Finally, Department interviews with the two care staff revealed that if they are feeding the residents, assisting them with toileting or changing their incontinence briefs, they are unable to answer calls, but do try to answer the phone during downtime. There was not enough evidence to support this allegation. It was also alleged that the Administrator is not present at the facility a sufficient amount of hours to manage the facility. The Department conducted an unannounced visit to the facility on October 8, 2025. The visit was not announced to the Administrators and during the visit, the back-up Administrator arrived to check-in and to conduct on-site staff training. Interviews with two residents revealed that they are familiar with the Administrators and one resident stated “they come all the time.” Interviews with two care staff revealed that the Administrator checks in often, sometimes in the late evening to check-up on the residents. (CONTINUED ON NEXT PAGE, LIC 809C) (PAGE 3 OF 4- CONTINUED FROM LIC 809-C) Finally, an interview with a resident’s Responsible Relative also revealed that they do not believe there are issues with the Administrator not being present at the facility. There was not enough evidence to support this allegation. It was also alleged that the Licensee accepted R1 into the facility even though R1 requires a higher level of care. Specifically, it was alleged that the resident requires care at the Skilled Nursing Facility (SNF) level and should not have been placed in a Residential Care Facility for the Elderly (RCFE). The Department conducted a records review. A review of R1’s Physician’s Report for Community Care Facilities, dated September 4, 2025, revealed that R1’s primary diagnosis is hemiplegia and hemiparesis, following cerebral infraction. R1 has incontinence issues and motor/impairment/paralysis, requiring assistance with Activities of Daily Living (ADLs). A review of R1’s Discharge Summary/Post-Care Instructions (DSPCI) from a Skilled Nursing Facility (SNF) revealed that R1 was discharged on September 6, 2025 with the following reason: “resident’s health has improved sufficiently, so the resident no longer needs the services provided by the facility.” The summary also indicated that R1 was discharged to a Board & Care and was enrolled to receive Home Health Services, including nursing and physical therapy. A Department interview with R1’s Home Health Clinical Director (HHCD) also revealed that, based on the doctor’s orders received by Home Health, R1 is currently receiving assistance from four clinicians, who visit twice per week to provide the following services: occupational therapy, physical therapy, bathing assistance and assessments conducted by a registered nurse. There was not enough evidence to support this allegation. Finally, it was alleged that staff are not meeting the resident’s care needs. Specifically, that staff are not assisting the resident to get out of bed and move daily. The Department interview with the Homed Health Clinical Director (HHCD) revealed that based on doctor’s orders, R1 was assigned to 2 days of physical therapy to get the resident out of bed and move. The HHCD clarified that the Home Health doctor’s order does not indicate that getting out of bed more than two days is required, but it is “preferred.” The review of R1’s Physician’s Report and their SNF Discharge Report revealed that there were no doctor’s orders indicating that the resident needed to be moved out of bed daily. An interview with R1’s Home Health Physical Therapist (HHPT) revealed that they assist R1 with physical therapy sessions two times per week based on doctor’s orders. The HHPT stated that they recently completed training with facility staff on how to use R1’s Hoyer lift to assist R1 to move out of bed. (CONTINUED ON NEXT PAGE, LIC 809-C) (PAGE 4 OF 4- CONTINUED FROM PAGE 3, LIC 809-C) The HHPT stated that they have requested R1’s family to assist R1 in moving more and have also requested facility staff to assist the resident in getting out of bed a few times per week, based on HHPT recommendations for R1 to move more. Department interviews with the two facility care staff revealed that they were recently finishing training on how to use the Hoyer lift for R1. Finally, an interview with the Licensee/Administrator revealed that due to health and safety concerns, the Licensee instructed care staff not to move R1 until Home Health provided training and instructions. There was not enough evidence to support this allegation. Due to a lack of corroborating evidence, the allegations that: staff do not ensure that resident's incontinence needs are met, that staff do not answer facility phone when resident's responsible party calls, that the Administrator is not present at facility a sufficient amount of hours to manage facility, that the Licensee accepted Resident #1 into the facility even though resident required a higher level of care and that staff are not meeting Resident #1’s care needs are unsubstantiated. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore, the allegations are unsubstantiated. This report was discussed with Cheryl Castro. A copy of this report, along with Licensee/Appeal Rights, (LIC 9058 03/22) were provided. Signature below acknowledges receipt of the documents.