complaint·October 1, 2025

On 03/26/2025, from 09:38am to 03:20pm, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced initial complaint investigation visit to the facility. During the visit, the LPA requested and received facility documentation relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings. On the allegation: Due to neglect, resident sustained multiple UTIs while in care. It was alleged Resident #1 (R1) had several UTIs while in the care of the facility. Review of R1’s file revealed R1 moved into the facility in April 2024, R1’s preplacement appraisal dated 3/7/2024 lists recurrent UTI under Health History and under Services Needed continence is marked “yes” with a note, “uses an adult diaper”. A physician report for R1 dated 3/12/2024 states R1 was not able to care for own toileting needs requiring assistance and did not have bowel or bladder impairment. A Resident Care Summary done by the facility dated 4/5/2024 states toileting needs as stand-by assistance, wears adult briefs for occasional accidents, incontinent of bowel and bladder. R1’s Service Plan completed 1/27/2025 indicates R1 as moderate toileting stand-by assistance with no additional notes. A facility care note for R1 dated 12/15/2025 states “Resident started a new antibiotic today for UTI. Nitrofurantoin mono/mac 100MG Take 1 capsule po 2x daily for 5 days”. The facilities medication administration record (MAR) show staff signed off the nitrofurantoin as administered to R1 per the physician order and this medication is logged into the facilities centrally stored medication record (CSMR) for R1. During R1’s stay at the facility from April 2024 to March 2025 the facility submitted four incident reports to CCLD for R1 with one of those dated 2/7/2025 resulting in a diagnosis of UTI and fall. The hospital discharged R1 with a new antibiotic medication for the UTI and facility notes for R1 dated 2/7/2025 states “Resident returned to the community with a DX of 1; Urinary Tract Infection 2;Fall. Antibiotics to be given, Cephalexin 500MG 1 capsule po every 12 hours for 5 days.” and “Started cephalexin at 8pm”. R1’s CSMR kept by the facility shows the cephalexin logged in by the staff, but the facility was not able to provide record showing each dose of the medication was administered to R1. The facility MAR and CSMR for R1 also indicates the antibiotic medication methenamine hippurate 1gm was started on 2/18/2025. On 3/1/2025 R1 had a fall at the facility, was sent to the hospital, diagnosed with multiple fractures to R1’s right wrist and shoulder, investigated as part of complaint 29-AS-20250313093906. Based on record review R1 sustained two documented UTIs while in the care of the facility, on 12/15/2025 and 2/18/2025. (Continued on LIC9099-C) During the investigation for complaint 29-AS-20250313093906 CCLD Investigations Branch (IB) Investigator Jorge Jauregui interviewed staff, residents, the facility Administrator and R1’s responsible person. Multiple interviews revealed that R1 not receiving proper toileting assistance from staff led to R1’s UTIs. Staff stated the facility was understaffed during R1’s time at the facility and had there been enough staff R1 may not have suffered the UTIs. The Administrator stated that they had no knowledge of R1 having a UTI or R1 prescribed a medication to treat a UTI. The Administrator also stated they believed the UTI developed from poor hygiene as staff were probably not changing her soaked diaper promptly and acknowledged the UTI could have been prevented if staff had changed R1’s soaked diapers promptly or if staff had paid attention to symptoms associated with a UTI. Multiple facility memory care medication technicians stated they did not know R1 had any UTIs and were not aware R1 was prescribed medication to treat the UTIs. Staff reported they lacked training on the causes of UTIs. However, the Administrator stated staff receive training on UTIs and their associated symptoms through courses such as Catheter and Perineal Care and Prevention of Urinary Tract Infections. Staff training record review indicates some staff interviewed received this training in the ten months R1 was in care at the facility, but there is no record of the memory care medication technicians interviewed completing this training during that time period. It is unclear how often staff complete the training. Based on all interviews conducted and record review, 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. On the allegation: Facility is not clean/sanitary. It was alleged there was a strong smell of urine in the assisted living side of the facility as well as the memory care unit of the facility. R1’s chair, wheelchair, stuffed animal, and mattress were stained and dirty. R1’s clothing also smelled. On 3/26/2025, LPA Haner-Tomasko and Administrator Carl Meyer toured the facility viewing several rooms in memory care including R1’s bedroom. At 10:29am in R1’s room LPA noted a strong smell of urine in the room, observed and photographed a soiled mattress, with multiple stains and some dirty clothing on the floor. The Administrator stated these were R1’s belongings and the wheelchair and chair that had been in the room must have been removed by family. Carl stated that the expectation is for staff to notify leadership of any stained furniture so it can be cleaned. (Continued on LIC9099-C) During subsequent visits to the facility due to additional complaints (29-AS-20250506110349 and 29-AS-20250630114830) regarding the facility not providing a clean environment for residents, LPA observed and documented on 5/7/2025 at 11:45am a memory care bedroom with a strong urine odor and in the south/east corner of the room the laminate flooring, baseboard, and wall paint peeling away from the floor and wall. At 12:40pm LPA observed and photographed a soiled chair in a resident’s room in the assisted living unit. On 7/8/2025 from 10:11am to 11:16am LPA observed and photographed stained and soiled bedding in 8 occupied resident rooms throughout the facility. Based on all interviews conducted and LPA observation, at this time the above allegation was found to be substantiated , there is a preponderance of evidence to prove that the alleged violation occurred. During a recent and similar complaint investigation 29-AS-20250506110349 on 7/23/2025 a citation was issued in line with Title 22, Chapter 8, Article 5, 87303(a) and a plan of correction was established. On the allegation: Facility does not have adequate amount of staff to attend to residents. It was alleged the facility does not have enough staff on duty for the number of residents in memory care. Residents cannot go to the outside area because there is not enough staff. Multiple staff interviewed during the investigation stated the facility often operated short-staffed and it was very challenging to provide the required supervision and care to the residents. Staff stated three caregivers in memory care seemed sufficient, but when there were less they could not meet the resident’s needs. The facility staff timesheets from June 2024 to March 2025, are missing numerous dates, and indicated the facility worked understaffed on multiple occasions. Multiple staff including the Administrator acknowledged that they could not provide prompt toileting or brief changing assistance to residents including R1. Based on all interviews conducted and record review, 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, deficiency cited on LIC9099-D, a civil penalty in the amount of $250 for a repeat violation of the same regulation cited in the last 12-months is assessed on the attached LIC421FC, report signed, report and appeal rights provided to the Administrator.