Per Record Review, LPA Tirre did not observe any incident reports related to alleged injury for R1.

Regarding Allegations Resident is left unattended for extended period of time and Resident incontinence needs are not being met while in care. It was alleged that R1 was left alone for long periods of time that they often had incontinent accidents due to not being taken to the bathroom. Investigation revealed the following: Per staff interviews, Three of three staff stated R1 was never left unattended due to facility always had staff present inside the facility. Three of Three staff stated that R1 needed full assistance with areas of daily living including toileting and staff stated they were available to help R1 whenever needed. One of three staff interviewed stated that resident wore pull up underwear and was not left soiled for periods of time. One of three staff stated they could not recall if R1 had incontinence issues. During visits to facility, LPA observed two staff members on duty who were attentive to residents’ needs. One staff member was checking on residents in bedrooms while another staff member was supervising other residents in common area.

The LPA attempted to identify and contact R1’s family members for interviews, however, no information was available during record review.

During Department visits, Department reviewed Resident records and observed that R1’s Physician’s report dated May 3, 2021, stated that R1 had diagnosis of Spinocerebellar ataxia stating R1 was wheelchair bound and fall risk. Physician’s Report also stated that R1 does not require continuous bed care and is able to communicate their needs.

CONTINUED ON 9099C

Regarding Allegation Staff speak inappropriately towards resident, it was alleged that staff were verbally abusive to R1, the investigation revealed the following: Staff interviews were conducted with three staff. Staff 1 stated that they never yelled or spoke inappropriately to R1. Staff 1 mentioned that R1 could be mean towards staff due to language barrier and stated that R1 would often tell staff “Oh you don’t understand me, this will be your last day, you are fired”. Staff 2 stated they never yelled at R1 or used profanity. Staff 3 stated that they never spoke inappropriately towards R1 and did not witness staff verbally abusing R1. Staff 3 stated that R1 was not pleased with any of staff at facility and often had an attitude and would belittle other staff for having foreign accent. LPA attempted to interview other residents but due to their medical condition’s interviews were not successful. The LPA attempted to identify and contact R1’s family members for interviews, however, no information was available during record review.

During visits to facility, LPA did not observe any staff speaking in an inappropriate manner to residents. LPA observed staff being courteous of residents asking residents politely about their needs.

Regarding Allegation residents are being mistreated while in care, it was alleged that residents were improperly mishandled, and the investigation revealed the following. Three of three staff were interviewed and three of three staff stated that R1 was not mistreated. Staff interviews stated that R1 was full assist and staff would often have to transfer R1 from chair to bed or chair to toilet. Staff 1 stated that they were never rough in handling residents and stated that R1 was very alert and often expressed if they did not like the way things were done. Three of three staff stated that staff tended to resident when needed assistance and if Resident requested for something. LPA observed R1 inside bedroom recliner resting and LPA was unable to interview at initial time of visit. LPA attempted to interview other residents but due to their medical conditions, interviews were not successful. The LPA attempted to identify and contact R1’s family members for interviews, however, no information was available during record review.

During visits, LPA did not observe any staff mistreating residents physically or verbally. LPA observed S1 move a resident from bed to wheelchair and did not observe S1 mishandle resident or resident complain about the way they were handled.

Per record review, LPA did not observe an incident reports related to residents being mistreated.

CONTINUED ON 9099C

Facility closed and had a change of ownership effective December 10, 2025. An exit interview was conducted via telephone with Licensee Carmen Achim and a copy of this report was discussed and mailed out to last provided address for Licensee.