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32 | [CONTINUED FROM LIC 9099-C, 2 of 3]
The Complainant said there was a period when R1’s hospital bed stuck out to the point that it obstructed their bedroom door from being closed. Interviews of managers, caregivers, and an outside source, along with video, showed: During late 2025, Licensee undertook a project to widen the doorframes of its residents’ bedrooms to make them more wheelchair-friendly. As part of this project, the shared bedroom door belonging to R1 and R2 was also widened. During the complaint period, R1’s/R2’s bedroom door could not be swung closed because it would contact the end of R1’s bed. After a few weeks, staff fixed the issue by rearranging/reorienting R1 and R2’s beds within the room to prevent blocking the door’s swing. Based on the specific circumstances and dimensions involved, CCLD concluded that the passageway into and out of R1’s bedroom was not blocked to the degree that people were materially slowed when coming in and out of the room. (However, the inability to close the bedroom door represented a privacy violation, which will be cited in a separate Case Management report.)
Complainant said facility staff let R1 lay atop bedsheets that were dirty with food residue, rather than put clean sheets on R1’s bed. During his 01/14/2026 and 01/28/2026 visits, LPA briefly observed the beds and bedding of the twelve (12) residents in care, finding all were reasonably clean. Of the ten (10) residents who could answer questions about this topic, all ten (10) affirmed that staff consistently provided them with clean sheets and bedding. Residents widely reported that facility caregivers typically changed their sheets and pillowcases twice per week on their scheduled shower days, plus on request. Interviews of the managers and caregivers corroborated this.
Based on records and interviews, a preponderance of evidence does not exist to show that that Licensee did not timely respond to resident(s)’ calls for assistance, that Licensee did not keep facility free of incontinence odors, that Licensee did not maintain facility cleanliness, that Licensee did not maintain comfortable facility temperature, that Licensee did not keep facility free of insects, that Licensee did not keep passageway free of obstruction, and that Licensee did not provide clean bedding. These seven (7) allegations are therefore Unsubstantiated, and no deficiencies were cited for them.
An exit interview was conducted with Licensee/Administrator Alex Limpin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today’s visit. |