Complaint·April 7, 2026

Report Continued from LIC 9099... It was alleged that staff do not ensure resident’s medical needs are met. It was reported that R1 may have been developing a urinary tract infection (UTI), and facility staff were made aware of the concern. However, staff may not have been providing adequate and timely care to address the resident’s needs. Record review and interviews conducted revealed that R1 was admitted to the facility on 07/19/2024. According to R1’s physician’s report dated 07/19/2024, the primary diagnoses included Mild Cognitive Impairment (MCI), acute UTI due to Pseudomonas, acute urinary retention, and ventral hernia, with a secondary diagnosis of hypertensive urgency. The report noted R1’s mental condition as confused and disoriented, with sundowning behavior. However, R1 was able to follow instructions and communicate their needs. The report also described R1 as ambulatory and able to dress, groom, and feed themselves, but requiring assistance with bathing and toileting. Per R1’s admission agreement dated 07/19/2024, page 4 under “Basic Services” states that the facility will assist with transportation by arranging services through a third-party provider upon request. Interviews indicated that when R1 expressed concern about a possible UTI, the information was immediately reported to R1’s POA. However, the POA stated they were unable to take R1 to a doctor’s appointment. Staff reported that R1 was offered transportation options, including a transit bus or a rideshare service such as Uber, to see their doctor. Staff further stated that they attempted to arrange transportation for R1, but R1 was reluctant to use public transportation. An interview with R1 corroborated staff statements that transportation was offered. However, R1 stated they were unfamiliar with public transportation and did not feel comfortable riding in a car with an unknown individual; therefore, they refused the offered transportation. Additionally, during interviews, R1’s POA expressed that they believed the facility was adequately caring for R1 and meeting their needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.