complaint·February 17, 2026

Allegation: Staff does not maintain cleanliness of resident’s room. I t is alleged that the facility did not clean soiled adult diapers containing urine under residents’ bed and by the wall. It is further alleged that the facility did not discard a tube of cream with feces stored in R1’s drawer. During staff interviews, Staff stated that resident rooms are checked and cleaned daily. Staff reported that caregivers are responsible for providing morning care, including changing residents, disposing of soiled diapers, and picking up trash observed during care. Housekeeping reported they clean resident rooms and bathrooms after morning care and complete additional cleaning as needed throughout the day. Staff acknowledged that some residents, including R1, frequently discard trash and soiled items on the floor or under beds. Staff stated that these items are addressed when observed or reported. Staff reported that caregivers and housekeeping work together to maintain cleanliness and denied that resident rooms are left unclean. Regarding the incident involving diapers found under R1’s bed, S1 stated the housekeeper assigned that day had just arrived and was unaware of the diapers. S1 reported the issue was discussed with the family, and staff responsibilities were reiterated. S1 denied observing neglect related to room cleanliness and stated that staff routinely follow up to clean resident rooms and remove trash. During R1 interview, R1 stated they are doing well and that everything is okay. R1 reported no complaints. During resident interviews R2-R4, residents R2–R4 reported they were doing well overall. R3 stated they are doing well; reported no complaints regarding the cleanliness of their room. R3 further stated they use plastic bed mats to step on because the floor is often cold, which is why LPA observed a plastic mat under their bed. R5–R7 had cognitive challenges and were unable to understand LPA’s questions. During the complaint visit, LPA conducted observations of resident rooms, including R1’s room. At the time of observation, the resident room appeared clean and orderly. No soiled diapers, trash, or debris were observed on the floor, under the bed, or in visible areas of the room. The resident’s bed, dresser, and surrounding areas were observed to be clean. LPA observed that in one (1) out of eight (8) bedrooms observed, crumpled plastic mats were present under the bed. Housekeeping had not yet been cleaned at the time of observation. LPA later learned that plastic mats are used by the residents for comfort because the floor is often cold. (continued on 9099C) Allegation: Staff does not provide toilet paper for residents. It is alleged that staff do not consistently ensure toilet paper is available in R1’s bathroom. During staff interviews, Staff stated that toilet paper is routinely stocked in resident bathrooms. Staff reported that housekeeping is primarily responsible for checking and refilling toilet paper in resident bathrooms during daily cleaning. Caregivers stated they also replace or add toilet paper as needed when they observe supplies are low or when residents request additional toilet paper. Staff acknowledged that certain residents use large amounts of toilet paper and may require frequent refills. Staff denied that residents are left without toilet paper and reported no known instances in which residents were unable to access toilet paper. During resident R1 interview, R1 reported no concerns regarding access to toilet paper. During resident interviews, R2–R4 reported no concerns related to toilet paper and stated they have access to additional toilet paper when needed. R5–R7 had cognitive challenges and were unable to understand LPA’s questions. During the complaint visit, LPA observed resident bathrooms to be stocked with toilet paper. Toilet paper rolls were observed present in resident bathrooms at the time of observation. No residents were observed without access to toilet paper, and no complaints regarding lack of toilet paper were reported to LPA during the visit. Allegation: Staff failed to provide adequate supervision to resident in care resulting in multiple falls. It is alleged that staff did not provide adequate supervision to the resident in care, resulting in resident falls. During staff interviews, staff stated that residents are supervised at all times. Staff reported that R1 walks independently using a walker and does not typically request assistance. Staff stated that R1 is permitted to walk independently, including outside in enclosed patio area which is consistent with his assessed needs. Staff 1 (S1) acknowledged that R1 has experienced falls; however, S1 reported the falls did not occur due to lack of supervision. (continued on 9099C) S1 stated one fall occurred outside when R1 bent down while attempting to use the restroom. S1 reported that following the falls, additional support was requested, including home health services, physical therapy, and use of a walker. S1 further stated that R1’s family was contacted immediately. S1 stated that staff provide reminders to R1 regarding restroom use. Several staff reported they were not aware of R1 having multiple falls and denied witnessing any falls. Staff denied concerns regarding supervision and stated that residents are monitored while outside through visual observation from inside the facility and through the use of outdoor cameras. During R1 interview, R1 reported no concerns in regard to supervision. During resident’s interviews R2-R4, residents did not report any concerns regarding to supervision. R5–R7 had cognitive challenges and were unable to understand LPA’s questions. During the complaint visit, LPA observed that the facility had outdoor cameras in place to monitor residents while in the patio area. The camera monitor was in the administrator’s office, and LPA observed the system to be operational at the time of the visit. LPA observed caregivers attending to residents and providing supervision during the visit. Based on the investigation conducted, which included interviews with staff and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. 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 . Exit interview was held, and a copy of this report was provided.