complaint·February 6, 2026

Continued form LIC9099) Regarding the allegation that staff left R1 soiled for an extended period. More specifically, RP reported staff left R1 soiled for hours without assistance. Department interviews reveal that  R1 confirmed requiring staff assistance for toileting and incontinence care. R1 reported occasional delays for staff response, but clarified this is not typical, as staff usually respond within a reasonable time. R1 also stated that staff assist with bed transfers and toileting multiple times daily . Department Interviews reveal the Executive Director indicated that pendant calls are answered promptly and that the Gardens area is staffed to meet resident needs, with additional support available from the South Building if necessary. Department interviews with residents, family members, and staff did not reveal any major concerns related to staff response times or incontinence care. Some individuals noted minor delays in answering call lights; however, there was no indication of inadequate supervision. Department records review of facility documentation and records did not produce evidence of neglect or prolonged soiling. During the visit, the Licensing Program Analyst observed R1’s room and noted no foul odors or unsanitary conditions. Regarding the allegation that staff did not timely address R1’s change in medical condition. More specifically, R1 throwing up for three days straight before nursing addressed R1. Department review of facility records reveal evaluations completed on January 18, August 6, and November 4, documenting reassessment of R1’s needs, including assistance with transfers, dressing, and toileting. Following the evaluations ED revealed that the facility encouraged R1 to relocate for closer proximity to care staff and coordinated two-person transfers when required. No evidence was presented that the facility failed to notify physicians or responsible parties of incidents. Interviews with staff and outside sources revealed no concerns regarding failure to address changes in condition. The Department has investigated the above-mentioned allegations and based on observation, interviews, and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Executive Director Neale whose signature below verifies receipt of these rights.