Complaint·January 8, 2026

8 Out of 13 residents state he/she does not require assistance with toileting needs. R5 and R7 states they do not know if staff assist with toileting needs. R6 and R8 state staff assist him/her with toileting needs. R13 did not respond to questions due to neurocognitive disorder. The Department interviewed 5 Staff (S1 to S5). 5 Out of 5 staff state he/she assists residents with their toileting needs. S1 states R1 has had toileting accidents, and staff will clean R1 immediately. S1 states R1’s responsible party was informed about R1’s toileting accidents in late April 2025/Early June 2025, when R1 had a toileting accident. S1 states R1 was cleaned by staff during this incident. The Department interviewed Witness 1 (W1). W1 states he/she does not have any concerns about the care his/her loved one is receiving at the facility. Review of R1’s physician’s report dated 7/7/2023, R1 can care for his/her own toileting needs. Review of R1’s care plan dated 6/18/2025 R1’s toileting assistance is three times per day, morning, noon and evening. Staff did not ensure resident’s room was maintained in clean condition. It has been alleged by the Reporting Party (RP) that R1’s room has ‘dirty laundry’ piled in the room, and staff are not washing the laundry. RP did not provide additional information regarding this incident. The Department interviewed 13 Residents. 7 Out of 13 Residents state the facility staff are cleaning his/her room. 5 Out of 13 Residents states he/she does not know how often staff clean his/her room. 1 Out of 13 Residents states he/she does not require assistance with cleaning his/her room. The Department interviewed 5 Staff (S1 to S5). 5 Out of 5 staff state resident rooms are being cleaned at least once a week, depending on the resident’s care plan. S1 states R1’s room is being cleaned multiple times a week, but it is not listed on R1’s care plan. S1 states R1’s agreement is for cleaning one time a week. Page 2 of 4 The Department interviewed Witness 1 (W1). W1 states he/she does not have any concerns about the care his/her loved one is receiving at the facility. Based on review of R1’s care plan dated 6/18/2025, states R1’s has ‘Spot Checks’ three times a day, morning, afternoon and evening. In addition, R1’s housekeeping and laundry assistance ‘0x, as needed.’ assistance ‘0x, as needed.’ On 9/25/2025 LPAs toured 22 resident rooms and observed all 22 rooms were clean and sanitary. Staff did not ensure resident’s showering needs were met. It has been alleged by the Reporting Party that R1’s showering needs were not met. RP did not provide additional information regarding this incident. The Department interviewed 13 Residents. 6 Out of 13 Residents state he/she does not need assistance with showering. R3, R6, R8 and R11 state staff are meeting his/her showering needs. R5 and R7 stated he/she does not know about showering needs, and R13 did not respond to the questions due to neurocognitive disorder. The Department interviewed 5 Staff (S1 to S5). 5 Out of 5 staff state resident’s showering needs are being met, residents are on a shower schedule. The Department interviewed Witness 1 (W1). W1 states he/she does not have any concerns about the care his/her loved one is receiving at the facility. Based on review of R1’s care plan dated 6/18/2025, states R1’s showering schedule as 1x per week on Monday, Wednesday and Friday. Review of Residents Shower schedule dated 6/6/2025 lists R1 on the shower schedule for Monday, Wednesdays and Fridays. Page 3 of 4 Staff did not dispense medication to resident as prescribed. It has been alleged by the Reporting Party (RP) that R1 was given the wrong medications and dosages for ‘almost 2 years.” RP states ‘for 22 months’ the facility did not update R1’s medications and doses from a third-party agency. The Department requested additional documentation regarding medications for R1, which RP did not provide. The Department interviewed 13 Residents (R1 to R13). 7 Out 13 Residents stated he/she has no concerns with receiving his/her medications. R2, R4, R8 and R9 state he/she does not need assistance with medications. R7 and R13 did not respond to questions due to neurocognitive disorder. The Department interviewed 4 Staff (S1 to S4). 3 Out of 4 staff state residents are receiving medications as prescribed. S4 states he/she is not a MedTech and does not know information about medications for residents. S1 states there was an incident in May 2025 involving a third-party agency for R1 requesting the facility adjusted R1’s medications. S1 states the third-party agency was told R1 needed a doctor’s order for any changes to medications. S1 state an updated medication order was received from R1’s physician after this incident. S1 states this incident was noted on R1’s progress notes. The Department interviewed Witness 1 (W1). W1 states he/she does not have any concerns about the care his/her loved one is receiving at the facility. Review of R1’s progress notes dated 6/19/2025 states on 6/10/2025 a third-party agency for R1 requested the facility change R1’s medication orders. On 6/11/2025 “new orders noted and carried out.” Review of R1’s medication dated 6/01/2025 to 6/30/2025 listed 4 medications updated on 6/11/2025. On 9/25/2025 LPA conducted a random medication audit of 3 residents. LPAs reviewed medication bottles with the centrally stored logs, no discrepancies were noted during the medication audit. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation are UNSUBSTANTIATED. . An exit interview was conducted, and a copy of this report was provided. Page 4 of 4 END OF REPORT