complaint·March 25, 2026

During LPA visit on 1/6/2025 LPA and Administrator Adam Bramwell toured the facility noting R1’s bathroom with yellow and brown dried substances on the toilet seat, brown dried spots on the bathroom floor, and the bathroom had a strong urine and fecal odor. Additionally in R1’s room multiple kitchenette cabinets had dried substances on the inside shelving, one drawer had a large spot of orange liquid spilled in it, another drawer contained a stained brown decorative pillow, the sink had dried food debris in it, and in the cabinet under the sink drainpipe the wood was stained, warping, and had multiple light grey, dark grey, and black spots. Upon inspecting all of the rooms in the Connections Neighborhood, memory care unit, the LPA and Administrator observed three additional resident rooms with grab bars, light switches and toilet seats with dried yellow and brown substances, all having a strong urine/fecal odor. Multiple stains were noted in the public hallway carpet in memory care with staff interviews revealing one of the carpet stains, brown in color, to be feces. Interviews revealed multiple staff had reported that specific stain to leadership on 1/5/2026. LPA photographed all the mentioned areas. Based on observation and all interviews conducted, at this time the above allegation was found to be substantiated , there is a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, deficiencies cited on LIC9099-D page, report signed, appeal rights and report provided to the Administrator. LPA review of R1’s record revealed R1 is diagnosed with dementia, struggles to communicate, has a contracted hand, is a one staff assist when toileting, has a private bedroom, and has a history of urinating in various spots of the facility. Regarding R1's toileting needs. Staff stated R1 will take themself to use the bathroom if the staff are helping other residents, R1 has a history of putting their hands in their feces, and staff monitor R1 for hygiene because of this. Staff are not aware of a recent time R1 had feces on their hands. Regarding R1's clothing, interviews revealed R1 will sometimes remove their pants independently, they will attempt to help R1 put the clothing back on, and there have been times when R1 has removed their pants, were sitting in their private room, and staff have offered R1 a blanket to cover their legs. Regarding R1's over-grown fingernails, staff interviews revealed they are not allowed to cut finger or toenails, but once month or every two months a podiatrist visits the facility, the facility has a beauty salon that residents or their responsible person can make appointments for them to have their nails cut, and care staff document on each residents shower sheet if they notice the need to have their nails cut. Staff also stated that due to R1's contracted hand it is difficult to open the hand for the nails to be cut, R1's family has been taking them out of the facility to have their nails cut on a regular basis, and currently a home health nurse has been monitoring and cutting the nails on the contracted hand, but the nurse is not always successful. Based on interviews and record review R1 does require assistance with their toileting, dressing and nail care needs and that the facility, home health, and R1's family are making efforts to provide R1 the care they need. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and report provided to the Administrator.