complaint·January 15, 2026

The investigation revealed the following: Allegation: Staff left residents in soiled diapers for an extended period of time The detail of the complaint alleges “the staff lets residents walk around with 'saggy' diapers in the facility instead of changing them.” On November 25, 2025, and January 15, 2026 the Department interviewed (A1) who denied the allegation stating that residents are not left soiled for an extended period of time. A1 further stated that the protocol for changing residents’ diapers: “…is based on typical checks of 1 to 2 hours and based on the needs of the residents whether they need to be changed and whether they are checked for urine output or bowel movements.” On November 25, 2025, between 8:00am and 4:00pm, the Department interviewed staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating they haven’t observed any residents left soiled for an extended period of time. 5 out of 5 staff stated that they are trained to care for residents who are incontinent. Additionally, 5 out of 5 staff stated that they typically change residents every 2 hours and/or sooner if necessary. On January 15, 2026, between 10:00am and 12:30pm, the Department interviewed 5 residents (R2-R5, R7) and Witness #1(W1). The department could not interview R1 as R1 no longer lives at the facility (passed away as of 11/24/25), R6 was not available at time of visit. Of those interviewed, 4 out of 5 state that they are never left in soiled diapers for extended periods of time. 1 out of 5 was not responsive to questions due to cognitive level. 4 out of 5 state that staff change them when they need changing. W1 a private/hire caregiver for R5 states staff is attentive and that she has not witness any instances where R5 complained of being left soiled since she worked with her. page 2 of 5 On January 15, 2026, the Department inspected 4 resident rooms and common areas and observed that the facility was clean, sanitary, and free of odors at time of visit. On January 15, 2026, the Department reviewed and evaluated the following documents: Incontinent Management Program policy (dated 12/1/23), staff training on caring for incontinent residents (dated: 1/2/26, 11/14/25, 8/11/25, 8/12/25), Service plans for R1, R2, R7 (dated 11/19/26, and 8/26/25). During review of the documents, the Department found that the facility appropriately maintains incontinent care for the residents. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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: Staff did not ensure the facility was free of odors The detail of the complaint alleges that the facility smells like urine. On January 15, 2026, the department inspected 4 resident rooms and common areas and the department observed that the facility was clean, sanitary and free of odors. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. Page 3 of 5 Allegation: Staff are not documenting incidents The detail of the complaint alleges “that when there is an incident, it is not documented.” On November 25, 2025, and January 15, 2026 the Department interviewed Administrator (A1) and 6 staff regarding the allegation. Staff and the Administrator denied allegation stating that incidents are always reported. S6 added, “Staff writes the incident down and they hand it to me, then I complete in the system and sign it, I also make sure they report the incident right away.” On January 15, 2026, the Department reviewed a sample of incident reports, which shows that the facility follows the reporting requirements. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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: Staff are forging medication logs The detail of the complaint alleges, “...they are told to sign logs for medications that they don’t have due to the refills not being delivered yet.” On November 25, 2025, and January 15, 2026 the Department interviewed (A1) and 6 staff (S1-S6). 6 out of 6 staff and A1 denied the allegation stating that there has been no reports of staff being asked to sign medication logs for medications they don’t have. Page 4 of 5 On January 15, 2026, the department reviewed and evaluated R1-R7 Medication Administration Record (MAR) for November and December 2025. The department found no evidence to support the allegation. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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. There were no deficiencies cited during today’s visit. Exit interview conducted with Administrator and copy of report provided. Page 5 of 5