At 12:13 p.m. conducted one (1) telephonic interview with the Power of Attorney (POA) for R1 and obtained copies of pertinent documentation relevant to the investigation. On 01/13/2026 at 1:42 p.m. conducted a telephonic interview with the facility DOS. At 2:25 p.m. and 4:00 p.m. attempted a telephonic interview with R1. At 2:28 p.m. and 4:40 p.m., attempted a telephonic interview with POA of R1.

On the allegations, Staff does not ensure resident is kept clean and dry at all times, and Staff does not ensure resident is kept free of mal odors it is the concern of the Reporting Party (RP) that R1 was covered in urine, had poor hygiene, and smelled foul. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation.

Interviews with POA revealed that R1 is considered independent living by receiving minimal assistance / basic services from the facility at the time. They have no concerns related to the care or hygiene of R1. POA stated that they believe the facility may no longer be the best place for R1’s care noting that they do not have additional funds to cover extra services and believe R1 may be declining due to age. They are in the process of relocating R1 to their hometown and do not see R1 returning to the facility after their current hospitalization.

Interviews with DOS revealed that on 12/13/2025 R1 was transported to the hospital via ambulance due to congestion and shortness of breath. As of 12/19/2025 R1 has not returned to the facility. R1 does not receive hands-on services from the facility, noting that the family is aware of R1’s level of independence and capabilities. R1 always appeared presentable and did not smell of a mal odor. They had no prior issues related to R1. To their knowledge and observation R1 upkept themselves. R1 would occasionally participate in activities but generally kept to themselves.

Report continued on LIC 9099-C PAGE 3...

Interviews with the Administrator revealed that R1 is independent requiring little to no assistance from the facility. R1 was always well put together, and they had no concerns regarding R1’s capabilities including hygiene. The Administrator stated that residents are always kept clean and dry noting that even residents who are not formally receiving services are supported. If grooming is needed staff address residents promptly. Additionally, the facility is responsible for ensuring residents are cared for appropriately.

Interview with Staff #1 (S1) revealed that on 12/13/2025 R1 had a meal tray delivered to their room. R1 was congested, not breathing well and their oxygen level was at 88. 911 was called. R1 was seated in a recliner chair. R1 was not soiled and remained dry throughout the incident and upon leaving the facility. R1 did not smell of mal odor.

Interviews with residents revealed that they are assisted by facility staff. To their knowledge they have not experienced or witnessed other residents being unkept, soiled, or smell of mal odor.

Interview with family visitor revealed that for the past four (4) months they have visited the facility regularly, unannounced at different times during the day. They have never had any problems or concerns with the quality of care. They have not experienced or witnessed residents being unkept, soiled, or smell of mal odor.

Record review revealed that R1 moved into the facility on 07/01/2025. R1 physician report dated 06/27/2025 indicated that R1 was diagnosed with Mild Cognitive Impairment (MCI), R1 does not have any bowel or bladder impairments, R1 is able to communicate needs, and R1 has the capacity for self-care. R1’s LIC 9172 – Functional Capability Assessment indicates that R1 can conduct Activities of Daily Living (ADL’s) on their own with no assistance. Additionally, R1’s care plan indicates R1 is fully independent. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur. Therefore, the allegations of Staff does not ensure resident is kept clean and dry at all times, and Staff does not ensure resident is kept free of mal odors are deemed unsubstantiated at this time.

Exit interview conducted. Report was reviewed and a copy was provided.