Complaint·October 27, 2025

LPA reviewed service records for resident #1 (R1) and requested copies of the following documents: Facesheet, Physician’s Report, Service and Care Plan, Resident notes (dated 07/14/25-07/19/25), Unusual Incident/Injury Report (dated: 07/21/25), and 2-Hour Rounds Check Policy Form. Additionally, LPA conducted interviews with staff #1-#5 (S1-S5), witness #1 (W1), attempted to interview witness #2 (W2), residents #2-#4 (R2-R4) and attempted to interview R1. On 09/11/25, LPA Gonzalez conducted interviews with residents #5-#6 (R5-R6), and S1. The investigation revealed the following: Allegation: Staff does not ensure resident receives sufficient continence care resulting in resident being left in multiple soaked diapers. It is being alleged that a resident came into the emergency department wearing 3 diapers that were all soaked through. On 07/28/25, between 10:20 AM and 12:00 PM, LPA conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff stated that they did not know if the above allegation happened. 5 out of 5 staff said they do not put more than one diaper on a resident. Interview conducted with S1 revealed that after conducting their own investigation, they became aware of two staff admitting to putting more than one diaper on a resident, and that they have taken the necessary disciplinary action. On 07/28/25, between 1:05 PM and 2:00 PM, LPA conducted interviews with R2-R4 and attempted to interview R1 but was unable to as R1 is in the hospital. On 09/11/25, between 1:00 PM and 1:45 PM, LPA conducted interviews with R5-R6. Of those interviewed, 5 out of 5 residents said don’t use diapers. 5 out of 5 residents said they don’t know if staff puts multiple diapers on any resident. Based on record reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. Title 22, Division 6 Chapter 8 are being cited on the attached LIC9099-D. An exit interview was conducted, and a copy of the report along with appeal rights was provided to Chansook Koo .