complaint·July 29, 2025

Regarding the allegation: Staff are leaving residents in soiled clothing for extended periods of time. It was alleged that residents were left unattended for hours causing them to urinate all over themselves. To investigate the allegation, LPA attempted interviews with eleven (11) residents and seven (7) staff members. LPAs interview with six (6) residents revealed that staff have never left them soiled for extended periods of time. Interview with R2 stated, “…I just push my button and they will come to change me”. Interview with R5 stated that the staff do not let them stay soiled, “…they don’t let me…the staff is great”. LPA attempted to interview R7-R11 but they were asleep during the time of the visit. LPA’s interview with five (5) staff members confirmed that residents are checked on hourly to ensure their incontinent needs are being met. Interview with S4 and S5 revealed that they have witnessed R2 and R5 being left soiled. LPA’s record review of R2 and R5’s Care Rounds revealed that both residents have had documented refusals of not allowing staff to assist them. During LPA’s physical tour, LPA conducted room checks of residents listed under incontinence care. In the memory care unit, LPA toured five (5) bedrooms and in the assisted living unit, LPA toured eleven (11) rooms. LPA observed the residents to be clean, well-groomed and did not experience any malodor. LPA did not witness any leak pads left soiled. LPA observed residents’ chairs, beds and flooring to be clean and in proper condition. LPA witnessed staff members conducting their rounds and assisting residents. Based on LPA’s interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not meeting residents toileting needs. It was alleged that residents’ incontinence needs are not being met by staff. To investigate the allegation, LPA attempted interviews with eleven (11) residents and five (5) staff members. LPA’s interview with six (6) residents revealed that staff do meet their toileting needs. Interview with R1 stated the staff keep them, “clean and dry”. Interview with R6 stated that they will push their button and staff will assist them with their toileting needs. LPA attempted to interview R7-R11 but they were asleep during the time of the visit. LPA’s interview with all staff members confirmed that residents who have incontinent needs are checked on to ensure their toileting needs are being met. During LPA’s physical plant tour, LPA observed residents to appear in good health. LPA observed residents to be clean and well-groomed. LPA did not experience any malodors within the facility. (Continue to 9099-C) Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Executive Director.