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32 | It was alleged that residents are left in soiled briefs for extended periods of time. It was also alleged that staff did not prevent residents from developing wounds on their legs. No further information regarding the allegations were provided, including resident names or incident dates. LPA interviewed seven (7) residents; no concerns were noted and residents had no information supporting the allegations. Staff interviewed stated that residents with wounds would receive wound care from outside home health agencies and not facility staff. Staff also stated that residents receiving incontinence care are checked multiple times per shift and also have pendants to call for care. LPA further reviewed incontinence care logs for a randomly selected resident that document daily incontinence care being provided. Based on interview and record review, the Department does not have sufficient evidence to corroborate the allegations. Although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that violations occurred, therefore, the allegations “Staff do not ensure residents' incontinence needs are being met” and “Staff do not prevent residents from developing pressure injuries” are deemed UNSUBSTANTIATED at this time.
It was also alleged that staff are providing spoiled food to residents. During the initial visit, LPA conducted a full physical plant tour, including the commercial kitchen. LPA inspected the kitchen area, refrigerator, freezer, and pantry area. No health and safety hazards were observed. Food was observed to be of good quality at the time of the visit. Staff stated that food is delivered twice a week from agencies like Sysco and FreshPoint. LPA interviewed seven (7) residents and observed resident rooms. Residents had no concerns of food quality and LPA did not observe spoiled food throughout the kitchen or in resident rooms. Based on interview and observation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff do not provide adequate food service” is deemed UNSUBSTANTIATED at this time.
It was further alleged that an unnamed staff member administered an unnamed incorrect medication to an unnamed resident, and that the error was not notified to the resident’s responsible party. During the initial visit on 01/15/2026, LPAs conducted a medication audit for six (6) residents. LPAs observed medications on residents’ centrally stored medications and destruction records (CSMDRs) that were missing medication start dates or had discrepancies with pill counts and recorded dates. The facility was cited on a separate LIC809 Required – 1 Year report on 01/15/2026 regarding the medication errors. However, no information relating to the allegation that staff administered the wrong medication to a resident was found. Report Continued on LIC9099-C.
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