complaint·March 11, 2025

obvious neglect of incontinence care. On 01/21/2025 LPA Jeffries conducted interviews with Staff 1 – 4 (S1, S2, S4, S4) all stated that R1 has incontinence issued with “digging” and are always addressed by staff when observed and as needed. LPA reviewed facility care plan for R1 that shows two showers per week. At this time there is not enough evidence to support the allegations of. “Staff do not ensure that resident’s incontinence needs are being met.” And “Staff do not ensure that residents are assisted with bathing. “ both are unsubstantiated at this time. As to the allegations of, “Staff do not respond to residents call for assistance.” and “Staff are not assisting residents with medications in a timely manner. “It was alleged that R2 was yelling “Help me” and no staff responded. It was discovered through documentation, observations, and interviews that on 11/21/2024 LPA conducted a physical tour of facility and observed R2 in their room. R2 was vocal during the LPA observation stating “lord help me” LPA observed S4 attending to R2’s needs. On 11/21/2024 LPA Jeffries conducted an interview with S4 who stated that R2 baseline is continually requesting staff assistance by calling out or yelling for staff. S4 stated that Staff check on all residents, including R2 approximately every 15 minutes or less. Interviews on 11/21/2022 with S1, S2, S3, and S4 all stated that residents are continually checked for any changes in conditions of residents. All stated they have high confidence in all staff and no staff are neglecting residents needs. On 11/21/2024 LPA Jeffries attempted to interview R1, R2, R3, and R4 all stated they feel safe in facility, however none answered screening questions when LPA was checking cognitive understanding. On 11/21/2024 LPA Jeffries reviewed R1 and R2’s Physicians reports, Centrally Stored Medication Records (CDMR), and Medication Administration Records (MAR)and found no abnormalities. At this time there is not enough evidence to support the allegations of, “Staff do not respond to residents call for assistance.” and “Staff are not assisting residents with medications in a timely manner. “ and are both unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Staff did not respond to resident's fall.” It was alleged that approximately between October 28 through November 3 of 2024 an unknown resident had fallen, and no staff assisted the resident. On 11/20/2024, 11/21/2024, and 11/23/2024 LPA Jeffries attempted to contact the reporting party (RP) by phone with no answered. As of 03/10/2025 there has been to return call from RP. On 11/21/2024 and 11/27/2024 LPA Jeffries reviewed facility serious incident reports (SIRs) which reviled the following: On 10/25/2024 a resident fell in their room, pressed pendant and staff address fall; accordingly, there was no other recorded resident fall in the time period of the alleged fall and there were no subsequent reports of resident injury within that time frame of the alleged fall. At this time there is not enough evidence to support the allegation of, “Staff did not respond to resident's fall.” and is unsubstantiated at this time. Exit interview, report read, and report provided.