Complaint·January 16, 2026

(Cont. from LIC 9099) The resident was found lying in the middle of the bed with water on the floor but the bed dry. Staff did not suspect a fall because the resident typically requires assistance to get out of bed and was found on the bed when checked. Staff consistently stated that they conduct routine checks every 1–2 hours overnight and use sound monitors, which function similarly to baby monitors. These devices allow staff to hear sounds coming from residents’ rooms during the night so they can respond promptly if additional assistance is needed. Attempts were made on several occasions to interview outside sources, including R1’s Power of Attorney (POA); however, no contact was successfully established during the investigation. LPA attempted to interview R1, however due to R1’s major neurocognitive disorder they were not able to be qualified for interview. During an unannounced facility visit, LPA observed R1’s room with clean sheets, clean floors, and free of hazards. R1 was observed asleep, clean and well-groomed. Pool noodles were observed attached to the bed rails for injury prevention while residents are sleeping. Staff explained that residents may toss and turn during the night and could hit their heads on the rails; the pool noodles are used as padding to reduce the risk of injury. This modification does not interfere with the intended purpose of the bed rails, which is to assist residents with mobility. A camera with a posted 'camera in use' notice was observed in the room, installed by R1’s POA for additional monitoring. Review of facility records corroborated staff interviews. R1's Plan of Care, LIC 602, Needs and Services Plan, and Resident Appraisal, reflects that R1 requires one-person assistance for all ADLs and needs frequent reminders for toileting. R1 is ambulatory with assistance or walker, and has some visual impairment. Records confirm reduced mobility and frequent confusion, due to dementia. The incident report was consistent with staff statements as staff documented that they found R1 on their bed with legs hanging off the edge, pants removed, and assumed urine on the floor. The incident was unwitnessed, and it was unclear whether a fall occurred as R1 did not express pain or discomfort, and was found on the bed, not the floor. The facility consulted a physician and nursing staff following the incident. R1's diaper check logs revealed routine checks throughout the day and every two hours overnight, including the day of the incident that occurred. Records did not give evidence that R1 was not being supervised according to their care plan and routine checks during the time of incident. (Cont. on LIC 9099-C pg. 1) (Cont. from LIC 9099-C) Regarding the allegations that staff left resident in a soiled diaper for an extended period of time, and staff did not shower resident in care, staff consistently stated all residents take showers every day or bed baths for non-ambulatory residents and that staff perform diaper checks throughout the day and at night. When residents have bandages or band-aids, staff stated they either use waterproof bandages during showers or remove the bandage prior to bathing and replace it with a new one afterward. Review of the facility records did not corroborate the allegations. R1's diaper check-in log revealed that staff conducted routine checks throughout the day every 3-4 hours, and every 2 hours throughout the night. Additional records revealed that R1's plan of care reflects that R1 requires one person assistance for all activities of daily living including daily showers. Regarding the allegation that staff did not report resident's incident to the resident's authorized representative, Staff interviews consistently stated that on October 10, 2025, at approximately 11:00 a.m., R1, who was seated in a wheelchair, slid down onto their buttocks. Staff reported that R1 did not express any pain or discomfort following the incident. The facility notified a medical clinic and communicated with a nurse, staff, and Community Care Licensing Division (CCLD) on the same day that the incident occurred. Staff stated that the resident’s authorized representative was not informed of the incident until 10/14/2025. Staff acknowledged that the POA could have been informed earlier, however it was reported within the required timeframe. Records review of the facility's incident report from 10/10/2025 were consistent with staff statements made during interviews. Text message correspondence on 10/14/2025 between staff and R1's POA were consistent with staff statements, as staff informed R1's POA of the incident four(4) days after it occurred. 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 ________ to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.