complaint·January 7, 2026

(Continued from LIC9099) The department interviews with staff as well as records review reveal staff reported that EMS(Emergency Medical Services) was called for serious falls, and the resident was transported to the hospital on multiple occasions between late January and mid-February 2025. Facility documentation reflects several falls during this period, with medical transports occurring for the most significant incidents. There is no documentation indicating that the staff or the POA refused medical care. The department Interviews with outside sources indicated differing perspectives: While some confirmed that facility staff responded appropriately and did not refuse medical care, others provided accounts suggesting concerns about the timeliness or adequacy of the response. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred; therefore, the allegations are UNSUBSTANTIATED . An exit interview was conducted with Executive Director Wes Hebner to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from lic9099) The department staff interviews revealed that staff reported hygiene care was provided daily and that supplies were available. Department records review revealed that facility documentation, including service plans, indicated regular care for R1. However, outside source interviews (OS1 and OS2) revealed frequent observations of R1, a resident of Compass Rose, in soiled briefs, sometimes saturated through clothing, upon their arrival. They stated they assisted R1 with incontinence care and showers during their visits. One source also described an incident involving another resident who remained soiled for approximately two hours before staff responded. Based on interviews, records review, and outside source statements, the Department determined that a preponderance of evidence exists to support that staff did not consistently meet R1’s hygiene needs as alleged. Therefore, the allegation is SUBSTANTIATED . An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.