complaint·April 7, 2026

The investigation revealed the following: Allegation #1- Staff do not meet incontinent care needs of residents. The details of the complaint alleged that the facility staff do not meet the incontinent needs of its residents. It was reported that staff often double brief a resident and have them go many hours without being changed. On 4/7/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not meet incontinent care needs of residents. All staff stated that they do meet the incontinent care needs of their residents. Staff stated that the residents are checked on every two hours throughout the day to see if they need to be changed. Staff also stated that some residents may need to be checked on more often, it all depends on their care plan and the needs of a particular resident. Staff further stated that it is not a practice to double brief a resident in the facility. The department interviewed residents (R1-R6) about the allegation and 6 of 6 residents that were interviewed stated that their incontinent needs are being met and that staff does assist them promptly as needed throughout the day. The department reviewed the Physician’s Report (Dated: 08/24/2021, 07/18/2023, 12/29/2022, 04/08/2025, 04/19/2023, 06/28/2023) and Resident Service Plan (Dated: 08/24/2021, 07/25/2023, 01/12/2023, 06/11/2025, 09/12/2023, 07/04/2023) and observed that there is a plan in place to assist those residents who are incontinent. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not meet incontinent care needs of residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation #2- Staff do not ensure hazardous items are inaccessible to residents. The details of the complaint alleged that the facility staff does not ensure hazardous items are inaccessible to residents. It was reported that the facility staff leave items that are hazardous to residents like shampoos, lotions, and ointments in reach of the residents causing a safety risk. On 04/7/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not ensure hazardous items are inaccessible to residents. All staff stated that the facility ensures that any items that are hazardous or unsafe for residents who have behavior issues are always in a locked cabinet. Staff further states that they have not observed any hazardous or unsafe items that were immediately accessible to residents nor has anyone complained about it. Report Continued On LIC9099-C The department interviewed residents (R1-R6) about the allegation and 6 of 6 residents that were interviewed stated that the facility staff does ensure that they are living in a safe environment; and they have not witnessed any hazardous or unsafe items in the facility or in their rooms. Based on interviews, there is insufficient evidence to support the allegation that Staff do not ensure hazardous items are inaccessible to residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation #3- Staff force residents to eat. The details of the complaint alleged that the facility staff force residents to eat. It was reported that staff force feed residents when they do not want to eat or give them Ensure instead of feeding them due to a lack of patience. On 04/7/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that Staff force residents to eat. All staff stated that they do not force any resident to eat when they do not want to eat. They also stated that force feeding a resident a meal is never acceptable under any circumstances. The department interviewed residents (R1-R6) about the allegation and 6 of 6 residents that were interviewed stated that the staff has never forced them to eat a meal. They also stated that they have never witnessed a staff member force feeding any other resident in the facility. Based on interviews, there is insufficient evidence to support the allegation that Staff force residents to eat. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation #4-Staff do not ensure that residents are provided meals. The details of the complaint alleged that the facility staff do not ensure that the residents are provided with adequate meals. On 04/7/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not ensure that residents are provided meals. All staff stated that the facility provides meals three times per day. They stated that residents are served breakfast, lunch, dinner, and snacks throughout the day. Staff stated that any resident who may have missed a meal, that meal is set aside for later if they choose to eat it, but no one is ever denied food in the facility. The department interviewed residents (R1-R6) about the allegation and 6 of 6 residents that were interviewed stated that the facility serves three meals per day, plus snacks. They all stated that they never went without a meal because the staff did not provide it for them. Report Continued On LIC9099-C The department reviewed the Welbrook Weekly Menu (Dated: 04/06/2026-04/12/2026) and observed that the facility does provide breakfast, lunch, and dinner for the residents in care. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure that residents are provided meals. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No citations were issued for this complaint investigation. An exit interview was conducted with David Cole, Vice President of Operations, and a hard copy of this Complaint Investigation Report was provided.