complaint·November 14, 2025

From 2:00 p.m. to 4:00 p.m., LPA interviewed five (5) staff, Resident #1 (R1) and Resident #2 (R2). LPA attempted to interview, Resident #3 (R3) and Resident #4(R4) but they did not clearly respond to LPA's questions. Allegation: Staff not keeping resident’s room free from odor. It was alleged S1 is not keeping residents room free from odor . To investigate the allegation, on 04/07/2025 at 9:12 a.m., LPA conducted a physical plant tour. During the initial visit LPA interviewed the administrator, the house manager, six (6) staff and (2) out of four (4) residents. During the physical plant tour, LPA did not smell any unpleasant odor in residents' bedrooms. LPA did not observe any items on the floor. Interview with five (5) staff corroborated they did not have concerns regarding S1 or with the facility's cleanliness. Staff corroborate it is part of their job duties to clean residents bedrooms. During interviews with residents they did not express concerns regarding the facility's odor. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff not changing residents diaper needs resulting in a rash. Regarding the allegation is was reported residents have sustained diaper rashes due to S1 not changing their diaper for an extended amount of time. A co-complainant reported it was R1 that had developed a rash. LPA's interview with the house manger denied the allegation. LPA's interview with six (6) staff deny the allegation stating R1 is able to go to the toilet with assistance and is provided timely assistance with diaper changing. Staff corroborate they do not leave residents soiled for an extended time and have not started a shift when a resident in a soiled diaper. According to staff, R1 is able to communicate when they have to use the bathroom or have had an accident. During interviews with residents they did not express concerns regarding assistance and R2 denied witnessing staff purposely delay responding to residents. LPA's review of R1 Physician's Report revealed R1 is not bowl or bladder impaired. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Page 2 of 3) Allegation: Staff not treating resident with respect. Regarding the allegation, it was reported that S1 is not nice to R1 and does not treat R1 with respect. LPA could not obtain specific details regarding the allegation. To investigate the allegation, LPA interviewed six (6) staff and one (1) resident. Interview with five (5) staff revealed that they have never witnessed S1 mistreat any residents. Interview with S1 denied the allegation. According to staff R1 may have disruptive behavior such as yelling but staff are able to redirect R1. LPA’s interview with R2 denied the allegation and they stated they have not witnessed R1 or any other residents being mistreated by staff. R1 did not respond to LPA's question regarding staff treatment clearly. LPA observed the interaction between R1 and S1 on 11/14/2025 and noted no signs of hostility. Based on LPA’s interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff left residents unsupervised for a period of time. Regarding the allegation, it was reported that S1 will leave their shift early and leave residents unsupervised. To investigate the allegation, LPA interviewed six (6) staff and one (1) resident. Interview with five (5) staff revealed that they have never witnessed S1 leave residents unsupervised. Interview with S1 denied the allegation. LPA’s interview with R2 denied the allegation. R1 did not respond to LPA's question regarding to supervision clearly. Based on LPA’s interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff did not assist resident in a timely manner. Regarding the allegation, it was reported that S1 told R1 to wait, resulting in R1 waiting approximately 20 minutes before receiving assistance. Interview with six (6) staff which includes S1 denied residents are asked to wait an excessive amount of time. According to staff they have asked residents to wait when they are already assisting a resident but it is not a long time. Interview with residents corroborated they have been asked to "hold on" but staff will provide assistance. Residents did not provide a time frame for response time. Based on LPA’s interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Staff was designated to sign todays report. No immediate health and safety issues observed during today's visit. Exit interview conducted and a copy of this report was provided to staff. (Page 3 of 3)