Complaint Investigation Report

LPA observed facility to be clean at the time of visit but the hallway to the resident’s room had an odor of urine. Witnesses also stated a resident’s bed linens have not been changed for several weeks. LPA observed all residents’ beds, several of them did not have the required linens in place and 2 of the beds had dirty blankets and linens.

Based on the evidence this allegation is Substantiated at this time.

On the allegation: Staff did not meet resident’s needs. LPA interviewed Witness which revealed witness came to visit and found R1 in bed in the flat laying position with a sandwich in hand and no staff present. LPA interviewed staff member which revealed R1 does need assistance with feeding. LPA observed staff feeding R1 at lunch time, R1 was up in wheelchair in the patio area at lunch time.

LPA reviewed Resident 1 (R1) records which revealed R1 is on hospice services, needs 2 person assist, according the R1’s LIC 602A dated 01/21/2026 R1 is not able to bath, dress or groom self, is incontinent in bladder and bowels, requires assistance with repositioning and transfers, on a special diet due to Dysphagia, and able to feed self but needs staff monitoring.

Based on the evidence this allegation is Substantiated at this time.

Exit interview completed, deficiencies cited and copy of report printed for Assistant Administrator/LVN.