complaint·November 21, 2025

[Continued from LIC 9099] On April 21st, 2025, R1 was given a 30-day notice from the facility due to failure to follow facility rules, specifically for engaging in verbal abuse against staff and other instances of disruptive behavior in common areas. Initially a cease and desist, dated March 7th, 2025 was provided to R1, however R1's behaviors continued, and the facility issued the 30-day notice. An appeal meeting with R1 was held May 27th, 2025 and on June 6th, 2025 the facility provided R1 with a notice of the denied appeal and an unlawful detainer was filed. File review of over ten (10) staff member statements throughout April and May 2025 revealed a pattern of racial and derogatory statements being made by R1 towards staff. Staff interviews corroborated abusive behavior by R1, as well as multiple outside sources interviewed. The facility followed regulations regarding eviction procedures and failure to adhere to facility policies falls under the list of valid reasons for evictions, per regulation 87224. Regarding the allegation of staff not preventing the development of R1's pressure injuries, review of R1's physician's report (dated September 2024) revealed R1 had no history of skin condition or breakdown and that R1 did not require continuous bed care. Interview with administrative staff revealed R1 had a history of pressure injuries and even had one prior to move in, which delayed R1's official move in as the facility requested the injury be treated and resolved before moving in. Review of R1's medical documents do note a history of stage 1 pressure injuries since 2020. Records reviewed revealed Home Health and Hospice treatment for R1's recurring pressure injuries from 2024-2025. Per staff interviews, though R1 was not formally bed bound (R1 is noted to be non-ambulatory on their physician's report) they spent most of their time in bed. Two (2) staff interviews corroborated that R1 had periodic sores in their genital area and facility staff would assist with applying ointments to the affected area(s) per instruction from Home Health. Home Health visit records note instructions for facility staff in care for the wounds. Interview with an outside source medical professional revealed that R1's diagnosed condition of Renal Disease contributes to the development of the pressure injuries. This interview also corroborated that facility staff assist in care for the injuries and keep the area clean. [Continued on LIC 812-C] [Continued from LIC 812-C] Regarding the allegation of staff not ensuring R1's incontinence care needs are being met, this is also entwined with the allegation of staff not answering R1's pendant calls in a timely manner. Per the complaint, R1 would regularly wait over an hour and a half for staff to respond to their pendant calls and that R1 has sat in their feces for nearly four hours before staff changed their briefs. Multiple staff and outside source interviews revealed that R1 tends to "exaggerate" their claims on how long it takes to be tended to, when in reality it's only been several minutes. Two (2) staff interviews revealed that R1 specifically calls around shift changes in order to know who is working. Per staff interviews, during shift changes there is a brief staff meeting to pass over information, which then can cause a slight delay in responding to calls during that time. Staff interviews revealed that as R1 is a two (2) person assist, it can take additional time for a secondary staff member to assist on a call if they are assisting someone else at the moment, one (1) mentioning that it on average takes up to 20 minutes to assist R1. The outside source medical professional interviewed revealed that there was no physical indication of R1 having been sitting in their stool for long periods of time as it would've been apparent on R1's pressure injuries. This interview also revealed that as R1 is fully incontinent, they cannot feel when they have had a bowel movement. Other residents interviewed revealed no concerns about the timeliness of staff responses to pendant calls or the speed of incontinence care. File review of R1's Needs & Services plan reveal that staff provide 3-4 brief checks per shift. File review of call button response logs for R1 for a span of three (3) months reveal that R1 utilized their call button on average ten (10) to fifteen (15) times a day and that the majority of calls were resolved within 25 minutes. However, on several occasions response times exceeded an hour, with two (2) being over 2 hours. Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Arp to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.