complaint·January 29, 2026

(Continued from LIC9099, Page 1) Interviews with staff revealed that during mealtimes, residents have the option of eating in the dining room, eating in their room, or refusing meals. Staff 1 (S1) and Staff 4 (S4) stated that residents who choose to eat in their room are not given food at the same time as residents in the dining hall, nor do they receive help from caregivers until the residents in the dining hall who require assistance are done eating. This can delay mealtimes for R1 who requests food in their room and require staff to assist with feeding. S4 stated that with regards to R1, they will check on them in their room during mealtimes, ask if they would like to eat with everyone in the dining room, and if not, they will offer a meal supplement/snack before R1’s dinner to help with the wait until they can finish assisting with dining room residents. Staff consistently stated that R1 will refuse meals and instead eat a meal supplement provided by their family. S4 told the LPA they believed it was possible that R1’s weight loss could be the result of R1’s eating habits at the facility (“R1 will only eat a couple of bites of their meals”) or a PRN medication’s side effects R1 takes daily. Additionally, S4 will ask R1 if they would prefer help with finger foods or sandwiches and assist based on R1’s preference. Interviews with residents revealed that there are times when food service is not prompt nor are staff present to assist if food is delivered to their room. R1 stated that staff are not consistent with bringing food on time and as a result R1 must rely on a supply of supplemental meals provided by their family to eat (this is not related to R1’s right to refuse meals which they will exercise on occasion). R1 told the LPA that there have been times when staff have delivered food to the room but will not stay to help feed them. This corroborates staff interviews. Interviews with outside sources revealed that Outside Source 2 (OS2) and Outside Source 3 (OS3) have observed R1’s experiences with the facility’s meal management. OS2 stated that they have called the facility in the past on an almost daily basis to check and confirm that R1 is fed at the beginning of mealtimes. OS2 and OS3 confirmed separately that there have been times they were with R1 at the facility and care staff did not provide notification or check on R1 for meal services. During those visits, OS2 has telephoned the staff from R1’s room asking if R1 was fed and reported that staff stated, “R1 refused food today.” OS3 told the LPA they were concerned about R1’s weight loss of 40 pounds during their time at the facility as a result of meal service inconsistencies. (Continued on LIC9099C, Page 3) (Continued from LIC9099C, Page 2) LPA observations of the facility revealed that when the LPA arrived to interview R1, R1 was receiving a meal service with assistance of a care staff member. Records review revealed that R1’s physician’s report from October 2025 states that R1 is able to feed themselves but requires assistance and supervision. R1’s physician’s reports dated from February and October of 2025 show that R1 lost 40 pounds which corroborates outside source interviews. 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 12/09/2025 it was alleged that " Staff leave resident in bed for an extended period of time.” The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff leave resident in bed for an extended period of time," it was alleged that facility staff do not check in on R1 frequently enough or offer activities and opportunities for Resident 1 (R1) to leave their room. Interviews with staff revealed that residents can participate in activities at the facility including walks around the neighborhood and planned events coordinated by the staff. Staff 2 (S2) stated that there are activities planned every day at the facility and that residents are welcomed and encouraged to join. Staff 4 (S4) stated that they try to encourage R1 to come out for meals and activities, but R1 typically refuses. In an interview with R1, it was stated to the LPA by R1 that they are dependent on staff to transfer to their chair. However, by R1’s own admission, they “stay in their room mostly by choice” and that staff “don't refuse to get [them] out of bed." This corroborates staff interviews. Records review revealed in physician’s reports that R1 is not bedridden and can ambulate around the facility with the use of a walker or cane. (Continued on LIC9099C, Page 4) (Continued from LIC9099C, Page 3) 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 ED Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. On 12/09/2025 it was alleged that "Staff yell at resident” The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff yell at resident," it was alleged that facility staff do not treat Resident 1 (R1) with respect by yelling at them while receiving care at the facility. Interviews with staff revealed that staff unanimously agreed that they had not heard or witnessed other staff members yelling at residents. Staff 3 (S3) stated that the only time they’ve heard staff raise their voice to a resident was out of surprise and trying to redirect a resident’s behavior. Interviews with residents revealed that staff do not normally yell at residents. R1 stated "No, caregivers don't yell at me,” and that, “care staff are normally friendly and helpful." This corroborates staff interviews. 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 ED Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.