Complaint Investigation Report

On 11/17/25 at 10:52 am, LPA conducted a telephone interview with the Reporting Party (RP). RP stated that during their visits, R1 has been soiled, and RP reported that documentation from the physical therapist and other nursing staff also indicates that R1 was found soiled on multiple occasions. RP additionally stated that during their visits, R1’s television was not working and that R1’s bedroom appeared “thrashed.”

On 11/17/25 at 2:50 pm via phone call, LPA interviewed Family #1 (F1) who stated that they believe R1 is choosing to be in a diaper, is very agitated, and refuses care such as changing, and showers. R1 refuses to go to doctor appointments, stated that a doctor saw R1 within the last week and agreed R1 should be on hospice, but R1 is refusing. F1 stated there is limited money, so they can only afford minimum care. F1 stated that the “facility is trying, but [R1] is being difficult.”

On 11/19/25 during initial visit LPA collected documentation of communication from the facility to the doctor, tracking records where staff note care attempted and results, medication lists, and Outside Provider Notes.

LPA was provided faxed communication from the facility to the doctor between 10/21/25 to 10/26/25 where the facility communicates R1’s increased anxiety, increased pain, declining to eat normally, declining staff assistance with Activities of Daily Living (ADLs), becoming incontinent, refusing assistance with changing their clothes and bedding and isolating themselves.

Notes regarding facilities attempt to provide care include documented services and attempts of services for: showering which states from 10/1/25 to 11/12/25 resident refused showers 10 times. Documentation of resident refusing housekeeping cleaning 2 times between 9/25/25 to 11/6/25. Documentation of incontinent care 3 times a day from 10/21/25 to 11/10/25 show resident refused care 10 times over a 20-day period.

On 11/17/25 LPA emailed a request for records from the Home Health agency. On 11/19/25 records were provided to Community Care Licensing which included “Visit Note Reports” dated from 10/6/25 to 11/13/25. Home health visit notes reflect ongoing concerns regarding R1’s environment, mood, personal care, and functional decline. Documentation shows 3 out of 12 visits with notes where R1 was found in a soiled condition or in a malodorous room, supporting the allegation. However, the same documentation also consistently indicates that R1 frequently refused care, resisted interventions, and declined assistance from both home health staff and facility caregivers.