complaint·August 20, 2025

Allegation: Staff took resident’s personal belongings Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1) and reviewed resident (R1) documents. Staff denied taking R1’s personal belongings (diapers). S1 stated R1 is very confused due to dementia and tends to wear 2 to 3 diaper pull-ups each time. On 08/20/25 at 1:30PM, LPA toured R1’ bedroom and observed R1 had sufficient incontinence supplies which ADM stated were purchased and delivered to R1 by her responsible party (POA) each week. Review of R1's admission agreement dated 05/13/25 showed the facility was not responsible for R1's incontinence supplies. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff took resident’s personal belongings is unsubstantiated Allegation: Facility is not feeding residents the appropriate quantity of food Investigation Finding: Unsubstantiated During investigation, staff (ADM, S1) stated R1 is very confused and does not remember events such as she already ate her meal and still thinks that she needs to have her meal. Prior unannounced visits conducted by LPAs on 05/21/25, 07/24/25 and 08/13/25 showed that LPAs observed residents were being served an appropriate quantity of food during lunch service. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility is not feeding residents the appropriate quantity of food is unsubstantiated. Continued on next page LIC9099-C pg1 Allegation: Staff did not provide proper incontinence care to resident Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1) and reviewed resident (R1) documents. On 08/20/25 at 1:30PM, LPA toured R1’ bedroom and observed R1 had sufficient incontinence supplies which ADM stated were purchased and delivered to R1 by her responsible party (POA) once a week. Review of R1’s admission agreement dated 05/13/25 showed no incontinence supply included. S1 stated R1 is very confused due to dementia and tends to wear 2 to 3 diaper pull-ups each time. Staff continually remind R1 that she only needs to use one diaper pull up. ADM stated that residents are monitored and diapers changed every two hours or as needed. LPA observed R1 to be hydrated, nourished and odor free. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not provide proper incontinence care to resident is unsubstantiated. Exit interview conducted and a copy of this report provided.