complaint·November 5, 2025

(PAGE 2) Report continued from LIC 9099... Starting at 10:29 a.m. LPA conducted in person interviews with the four (4) staff including the Designee and Assistant Administrator, two (2) residents including Resident #1 (R1), a telephonic interview with the Power of Attorney (POA) of R1, a record review, medication review and audit and obtained copies of pertinent documents relevant to the investigation. On the allegation Staff does not ensure resident does not sustain pressure injuries, it is the concern of the Reporting Party (RP) that R1 was observed to have bed sores. To investigate this complaint, LPA Mosley conducted interviews with four (4) staff, two (2) residents including R1, a telephonic interview with the POA of R1, a record review and obtained copies of pertinent documents relevant to the investigation. Interviews with staff revealed that R1 has been on hospice care since 10/29/2025. R1 does not have any bed sores. However, R1 has a wound on their right ankle that originated as a pimple and was frequently scratched by R1, resulting in an open wound. R1 is seen by their hospice nurse two (2) times per week and by a wound care specialist two (2) times per week, during which the wound is treated. Interview with R1 revealed that they have had a metal plate in their right ankle for many years. They developed a pimple-like bump on the ankle, which they repeatedly scratched, leading to an exposed wound. R1 is currently seen by a nurse three (3) to four (4) times per week for wound care. R1 confirmed that they do not have any pressure injuries. Interview with the POA confirmed that R1 does not have any pressure injuries. The POA stated that R1 has a metal plate in their ankle and developed a pimple-like bump, which R1 scratched open, leaving it exposed. As of 10/29/2025, R1 has been on hospice care and receiving wound treatment for the injury. R1 has not sustained any pressure injuries while at the facility. Record review confirmed that R1 has been on hospice care since 10/29/2025 and is seen by a wound care specialist two (2) times per week. Wound care is documented in R1’s care plan. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff does not ensure resident does not sustain pressure injuries is deemed unsubstantiated at this time. On the allegation Staff does not ensure resident's bathroom needs are being met it is the concern of the Reporting Party (RP) that R1 needed to use the bathroom and staff did not assist. To investigate this complaint, LPA Mosley conducted interviews with four (4) staff, two (2) residents including R1, a telephonic interview with the POA of R1, a record review and obtained copies of pertinent documents relevant to the investigation. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099-C PAGE 2... Staff interviews revealed that they assist all residents with using the bathroom at a minimum of every two (2) hours. After each meal, staff escort residents to the bathroom and encourage them to try. R1 has the capacity to request bathroom assistance and frequently does so. When R1 asks to use the bathroom, staff respond and assist as promptly as possible. Staff consistently assist residents with their bathroom needs.Interviews with R1 revealed that they have not experienced any issues with staff assistance regarding bathroom use. R1 stated they would not allow such issues to occur and confirmed that their bathroom needs are being met. R1 affirmed that staff have always assisted them whenever needed. Interview with Resident #2 (R2) revealed that they have not encountered any concerns with staff assistance for bathroom use. R2 also stated that they have never observed any other residents experiencing issues with bathroom assistance. Interview with the POA revealed that they have been involved with the facility for several years and have not had any issues or concerns. They expressed satisfaction with the care being provided and confirmed they have not witnessed any concerns related to staff assistance with bathroom use. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff does not ensure resident's bathroom needs are being met is deemed unsubstantiated at this time. On the allegation Staff left resident on floor for an extended period of time it is the concern of the Reporting Party (RP) that a resident slid out of their wheelchair and staff were unable to help get them up. To investigate this complaint, LPA Mosley conducted interviews with four (4) staff, two (2) residents including R1, a telephonic interview with the POA of R1, a record review and obtained copies of pertinent documents relevant to the investigation. Interviews with staff revealed that the facility typically schedules two (2) staff members during the morning and evening shifts, and one (1) staff member during the night shift. Staff reported that no residents have recently slid out of their wheelchairs. In the event that a resident were to slide out of their wheelchair, staff would respond promptly. Staff emphasized that residents are not left on the floor for an extended period of time.Interviews with residents revealed that they have not witnessed any resident slide out of their wheelchair. They also stated they have not observed any resident left on the floor for an extended period of time. Residents confirmed that staff are prompt in providing assistance and expressed no concerns regarding staff response times.Interview with the POA revealed that they have not witnessed any resident left on the floor for an extended period of time. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff left resident on floor for an extended period of time is deemed unsubstantiated at this time. Report continued on LIC 9099-C PAGE 4... (PAGE 4) Report continued from LIC 9099-C PAGE 3... On the allegation Staff does not ensure resident is provided adequate food service it is the concern of the Reporting Party (RP) that R1 seemed very hungry while the facility and tells the family that R1 does not eat. To investigate this complaint, LPA Mosley conducted interviews with four (4) staff, two (2) residents including R1, a telephonic interview with the POA of R1, a record review and obtained copies of pertinent documents relevant to the investigation. Interviews with staff revealed that R1 is a particular eater and enjoys restaurant food. R1 consumes small portions. Staff encourage R1 to eat as much as possible but respect that R1 has a limited appetite. At times, R1’s family will order DoorDash meals for R1, as they prefer restaurant food. R1 typically eats only a small amount of the ordered food, leaving leftovers that are offered again later in the day. Interviews with R1 revealed that they are a picky eater and enjoy restaurant food. While the facility provides good-quality meals, R1 prefers restaurant options. R1 is consistently provided with nutritious meals. If R1 feels hungry, the facility offers additional food or snacks. R1 reported no issues with food availability or access. Interview with the POA confirmed that R1 receives nutritious meals at the facility. R1 enjoys restaurant food, and staff make every effort to encourage R1 to eat. The POA expressed no concerns regarding the meals provided to R1. They acknowledged that R1’s appetite has declined over the past couple of years, but noted that the facility continues to make efforts to support R1’s nutritional needs . Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff does not ensure resident is provided adequate food service is deemed unsubstantiated at this time. On the allegation Staff is mismanaging resident's medications it is the concern of the Reporting Party (RP) that R1 has medication that must be refrigerated and was left out on the counter. To investigate this complaint, LPA Mosley conducted interviews with four (4) staff, two (2) residents including R1, a telephonic interview with the POA of R1, a record review, medication review and audit and obtained copies of pertinent documents relevant to the investigation. Staff interviews revealed that they follow all residents’ medication directions and instructions. Currently, there are no residents receiving medications that require refrigeration. Staff state that medications are not left accessible. Interviews with R1 revealed that they are aware of the medications they are taking, none of which require refrigeration. R1 reported no issues with their medications. Interview with the POA confirmed that R1 is not prescribed any medications requiring refrigeration. Report continued on LIC 9099-C PAGE 5... (PAGE 5) Report continued from LIC 9099-C PAGE 4... The POA stated they have no concerns regarding R1’s medication management. Record review indicated that R1 does not have any medications requiring refrigeration. Medication audit showed that R1’s medications are properly labeled and checked for expiration dates. All medications, including PRNs, were appropriately labeled, securely stored, and locked, making them inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and accurately documented on the centrally stored medication and destruction records. No errors were observed during the review. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff is mismanaging resident's medications is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.