complaint·December 4, 2025

Continued from LIC9099... S1 also stated that R1 can become combative and often refuses any assistance from staff. Interview with Health and Wellness Director (HWD) indicated that R1 had blisters that healed before becoming open sores and therefore were not staged. Interview with R1 indicated that they are checked on, provided assistance when required, have all their meals delivered to them, and have their room cleaned at least once a week. Further interview with R1 indicated that they have had issues at the facility with call alarm waiting times, assistance with shifting in bed, and developed four (4) sores on their back. LPA observed that R1’s room was fully furnished and clean, and LPA did not observe a musty odor present. R1 was observed to be lying in bed with sheets covering them and a caregiver was observed to check on them regularly. Review of third-party Resident Service Note Charting Forms from 06/2025-11/2025 indicated Stage 1 pressure wound that healed within two (2) weeks. Review of Resident notes dated 06/2025-10/2025 show an average of three (3) checks a day for R1 with daily notes documenting R1 refusal of care. Although the allegation may have happened or is valid, the Department has found there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . No deficiencies cited. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.