Regarding the facility allegation of residents bedding is left soiled for a long period of time revealed the following: It was alleged that facility staff left Resident #2(R2) in their soiled bed for three weeks. LPA reviewed a physicians report dated January 1, 2023, stating that R2 was diagnosed with dementia, does not require continuous bed care, did not have bladder or bowel impairment, was unable to communicate their needs, was able to care for their own toileting needs and was considered non ambulatory. Two of three staff informed LPA that residents are checked for brief changes every two hours unless needing a changing sooner. Two of three staff informed LPA that caregivers are able to change residents sheets even if they are still in the bed. Two of three staff informed LPA that R2 was difficult to change, but the staff never left them soiled for an extended period of time. Continue on 9099C

Regarding the allegation of facility staff did not provide adequate supervision resulting in a resident consuming another resident's medication revealed the following: It was alleged that Resident #3 (R3) drank Resident #4(R4) medication that was crushed and put in their drink. LPA reviewed a physicians report dated November 4, 2021, stating that R3 was diagnosed with dementia and was able to feed themselves. LPA did not observe an updated physicians report for R3. LPA reviewed a physicians report dated November 21, 2022 for R4 stating that R4 was diagnosed with dementia and is able to feed themselves. LPA did not observe an updated physicians report for R4. Three of three staff informed LPA that they do not walk away from the resident until all the medication has been consumed to ensure that another resident does not pick up their cup. One of three staff informed LPA that R2 is unable to drink unassisted, so staff would help them drink the juice with their medication. The Department attempted to interview R3 and R4 and they could not confirm or deny the allegation. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed updated staff medication training dated June 8, 2025, and October 29, 2025, for two of three staff. One of three staff does not do medication distribution in the facility. LPA did not observe medications accessible to residents at the time of the investigation. LPA observed the medication room and the medication cart to be locked on both of the facility floors.

Regarding the facility allegation of resident was left in the same clothing for a long period of time revealed the following: It was alleged that Resident #5(R5) was left in the same clothing over an entire weekend without being changed. LPA reviewed a physicians report dated April 27, 2022, for R5 stating R5 was diagnosed with dementia and was able to dress/groom themselves. LPA did not observe an updated physicians report for R5. Two of three staff informed LPA that R5 wore similar clothing everyday which included a tshirt and levi jeans. Two of three staff informed LPA that R5 looked the same everyday due to their clothing being so similar. LPA was unable to interview R5 due to them not residing at the facility. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed three of three staff have resident personal rights training completed in 2024.

Continue on 9099C

An exit interview was conducted and a copy of this report was provided at the time of the investigation.