complaint·October 21, 2025

Report Continued from LIC 9099... Records review and interviews conducted revealed Resident #1 (R1) was admitted to the facility on 08/31/2024. Per R1’s physician’s report dated 06/19/2025, R1’s primary diagnosis include dementia and a recurrent sacral pressure ulcer, with a noted lack of capacity for self-care. Per updated Resident Assessment dated 01/28/2025, it indicates that R1 requires hands-on assistance with all grooming and hygiene tasks. This includes assistance with showering or bathing 1–2 times per week, dressing and undressing twice daily, as well as toileting needs. It was alleged that staff are not meeting resident’s oral hygiene needs and staff are not meeting resident’s grooming needs. It was reported that R1 had significant buildup on their tongue and their skin appeared extremely dirty. Records review and staff interviews revealed that R1 was receiving services from Buena Vista Hospice. According to staff interviews, hospice staff provided R1 with showers twice a week, while facility staff gave sponge baths on the other days. Staff also stated that R1’s teeth were brushed daily and that R1 did not refuse oral hygiene care. They also added that any refusals of care are typically documented and communicated between staff; however, there were no refusals reported during the visit. Additional interviews revealed that R1 had specific preferences regarding which staff members assisted with their oral hygiene and grooming. Furthermore, an interview with R1’s family indicated that they visited R1 frequently—several times a week—and consistently observed that R1 was clean and well cared for and reported no concerns regarding R1’s care while residing at the facility. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “staff are not meeting resident’s oral hygiene needs” and “staff are not meeting resident’s grooming needs”. Therefore, these allegations are deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was issued.