complaint·January 14, 2026

(Continued from LIC9099, Page 1) Interviews with staff demonstrated knowledge of the rights of residents. Facility staff consistently stated that call times for the signal system were typically no longer than 15 minutes to respond. Staff 2 (S2) stated that there are times when staff will check on two residents who used the call system at the same time and prioritize urgent or emergency calls vs lower level need calls like transportation to the dining room during meal times. Consent from the residents to answer another call is required and obtained. Interviews with outside sources stated that on the night the allegation occurred, that it took no more than 10-15 minutes for staff to check on R1. This corroborated staff interviews. Outside Source 3 (OS3) stated that during their time at the facility, they have used the call system less than four (4) times and each time the facility's response was either immediate or within a few minutes. Records review revealed that on the day of alleged call, the signal system recorded the call time, response from the facility, and thereafter cleared response which took less than 12 minutes. This contradicts the allegation that it took around an hour for facility staff to respond. LPA Observations of the signal system revealed that while at the facility, LPA activated the system and staff arrived within three (3) minutes of the alert. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. On 11/07/2025 it was alleged that "Staff do not ensure that resident's care needs are being met while in care." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff do not ensure that resident's care needs are being met while in care," it was alleged that when facility staff check on R1 during the overnight shift, they do not perform their required incontinence checks/assist R1. (Continued on LIC9099C, Page 3 (Continued from LIC()((C, Page 2 ) Staff interviews revealed that incontinence care checks for all residents occur throughout the day at the facility. Staff confirmed concerns from the outside agencies involved with R1's care. S2 stated that the outside agencies were concerned in the past about R1's incontinence care and stated that the facility has held meetings with R1's care team with the intent to build better communication and ensure R1 is taken care of. Outside Source interviews revealed that outside sources have worked with the facility to ensure R1's continued care. OS3 stated that, "There were some times that staff did not check on R1; however, we brought those concerns up… Neglect is untrue.” Outside Source 2 (OS2) stated that, "Overnight staff are doing a good job checking overnight for R1. I have no concerns about the facility's ability to take care of R1." Records Review revealed that service plans developed before and after the allegation date show the facilities ongoing cooperation with Private Caregiver's and hospice to ensure R1's incontinence care is taken care of. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Scottie Geno, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.