complaint·March 14, 2026

Following is a summary of the allegations and investigation finding: Regarding allegation “Staff left resident on floor for an extended period of time” – Information was received that resident #1 had two fall incidents and was left on the floor for an extended time. Also, additional information received that when resident fell (date unknown) R1 contacted the family member who lives close to the facility for help/assistance back into bed. To investigate this allegation, records reviewed revealed that R1 had two falls one on 2/11/2025 and another on 3/23/2025 since admission to the facility memory care on 2/20/2024. Service care plans dated 10/07/2024; 11/24/2024 and 3/26/2025 documented that R1’s level of assistance in mobility/ambulation was minimal to moderate; just prompting and cueing; not required hands on. Records reviewed indicated R1 requiring escort/redirection in the memory care unit and encourage use of walker. Regarding fall incident on 2/11/2025 it was documented that R1 sustained a fall in resident bathroom; R1 fell in the bathroom; R1 had a cell phone which R1 used to call family. The family contacted the facility at which time staff went to assist R1. R1 was found on the floor in R1’s bathroom (incident time documented 8:30pm). The second fall was on 3/23/2025; R1 was out with family; upon returning to the facility R1 sustained a fall transferring out of the family car. Staff were alerted and attended to R1 accordingly. In both fall incidents 911 was contacted and R1 was transferred to the hospital. Staff reported that all residents in memory care are out during the day in the common areas and constantly monitored by staff. Staff stated that when residents are in their room at night, they are checked on at minimum every 2hrs. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff left resident on floor for an extended period of time” is deemed unsubstantiated at this time. Regarding allegation “Resident sustained a pressure injury while in care” – Information was received that R1 had a level 1 pressure sore which was do to leaving R1 unattended for long periods each day. R1’s records reviewed did not indicate/note any pressure injury. Interview was conducted with Infinite home Health registered nurse (RN). RN reviewed R1’s records and confirmed that R1 did not have any pressure injury. RN verified through their records that the family took resident to the doctor on 05/08/2025 at which time the doctor provided R1 a referral for home health service; as precaution due to small (dot size) pink rash to R1’s sacral area. RN verified that an LVN from the home health agency evaluated R1 on 5/9/2025, 5/14/202 and on 5/20/2025 and no wound was observed. RN confirmed that they evaluated R1 on 6/2/2025 and no wound was observed to stage. (Continue to 9099c) Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Resident sustained a pressure injury while in care” is deemed unsubstantiated at this time. Regarding allegation “Staff leave resident soiled for extended periods of time” - Information was received that R1 was observed continuously found with a full diaper. Records reviewed and interview conducted with staff revealed that for hygiene and toileting, staff wound provide verbal prompts and cues. Staff reported that despite engorgement from staff R1 continuously demonstrated refusal of assistance with hygiene care and showers. Staff state that the family and doctor were informed. Staff reported that despite R1 refusing hygiene care, R1 was reminded and encouraged good hygiene care; family and doctor were aware of the situation. Staff interviewed reported that residents requiring assistance with toileting and showers are always assisted with hygiene care. Staff reported that residents are not left unclean or unsanitary. LPA attempted to interview residents in the memory care however they were unable to interview due to cognitive difficulties. LPA did not observe residents in the memory care unit soiled or unkempt during the initial visit and subsequent visits thereafter for other reasons. Visitors in the memory care unit interviewed during the initial visit expressed satisfaction with the care team services. Assisted living resident interviews were also conducted and five (5) out of five (5) residents interviewed reported no issues with care service provided by staff. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff leave resident soiled for extended periods of time” is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.