complaint·November 13, 2025

Regarding: Staff does not ensure resident’s diapering needs are being met. It is alleged that staff only change resident’s diaper three times a day in a 24-hour period. It is also alleged that families have complained that resident’s diaper should be changed more than three times a day. Staff deny the allegation. Interviews with (5) out of (5) staff revealed that residents’ incontinence care (diapering) is being conducted more than three times a day in a 24-hour period. Staff indicated that every staff shift begins with rounds which consist of providing incontinence care for residents. Staff indicated that incontinence care is done every one to two hours and when needed in between scheduled checks. Staff also indicated that staff ensure that residents that require a higher level of care are checked and changed more frequently, and that independent residents who can do their own incontinence care are observed and assisted if requested. Staff further stated that they have not received any complaints from family members of residents regarding incontinence care. Four (4) out of (5) staff stated that they check the resident logbook during their shift to check notes documented by staff who previously cared for residents to continue meeting diapering needs appropriately throughout the day. Record review indicated that staff document incontinence care after it is conducted by indicating the date and time of the event, and the name of the resident and the staff who performed the task. Records also indicated that no more than two hours pass between diapering and other personal hygiene tasks. LPA inspected the incontinence storage room and observed sufficient supplies of incontinence care items for residents. Interviews with (8) out of (10) residents revealed that their incontinence needs are being met appropriately and that staff check in on them often throughout the day. Two (2) out of (10) residents indicated that they do not need help from staff to conduct their “diapering;” however, staff provide them with the supplies they need to conduct their personal hygiene. Staff and resident interviews, record review and observations do not corroborate the allegation that staff are not ensuring that diapering needs are not being. ***Continues on LIC 9099-C page 2 Regarding: Staff does not ensure to keep up with residents' housekeeping needs. It is alleged that facility has only one housekeeper and that housekeeping has not been keeping up with sweeping and mopping residents’ rooms. It is also alleged that staff are not taking out the trash in residents’ rooms. Staff deny the allegation. Interviews with (5) out of (5) staff revealed that facility is not short of housekeeping staff and that all staff contribute to maintaining the facility clean during their shifts. Staff indicated that sweeping and mopping starts at 6:00 a.m. which is done by the night shift staff. Staff indicated that sweeping and mopping continues throughout the day after breakfast, lunch, dinner and as needed. Staff stated that resident rooms are mopped every other day; however, spills and accidents due to incontinence are cleaned up immediately. Staff further indicated that trash bags are taken out of the residents’ rooms daily, especially after “diapering” soiled items have been removed from residents and disposed of in the trash cans. Staff stated the cleanliness of the whole facility, including residents’ rooms, is not just the responsibility of the housekeeping staff, but of all staff in general. Interview with (1) out of (10) residents indicated that sometimes resident has to take out their own trash bag; however, for the most part, staff clean resident’s room often. Interviews with (9) out of (10) residents indicated that staff are sweeping and mopping their rooms and taking out their trash bags often and have no concerns about staff not cleaning their rooms. LPA inspected (11) resident rooms and observed the floors to be clean and trash bins to contain clean liners. Inspection of the cleaning supply room indicated that the facility has sufficient cleaning supplies readily available for use. Staff and resident interviews and observations do not corroborate the allegation that staff are not keeping up with residents’ housekeeping needs. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Rosalie Sandoval, Executive Director and a copy of this report was provided.