Complaint·May 28, 2025

Investigation revealed the following: Allegation: Staff did not ensure resident's incontinence needs were being met The complaint alleges that during the period of 5/17/25 - 5/18/25 the staff “were not changing and cleaning R1.” On 5/28/25 at 11:56 am, LPA interviewed Administrator (A1) who denied allegation stating that staff tends to all residents’ incontinent needs, "they are always changed when they need to be and the staff constantly check to see if the resident needs changing." A1 further stated that “As long as they are wet, the staff will change them at once.” Lastly, A1 informed LPA that the staff checks the residents every hour. On 5/28/25, between 9:30am and 1:00pm, LPA interviewed 2 staff (S1-S2)regarding the allegation and (2) out of (2) staff denied the allegation stating; residents are changed on a regular basis, and they are check often and changed at least 4 times a day depending on the need. (2) out of (2) staff stated that they have adequate training on how to care for residents who are incontinent. On 5/28/25, between 1:00pm and 2:00pm, LPA interviewed 3 Residents (R2-R4)). R1 and R5 could not be interviewed as R1 no longer resides at the facility and R5 is nonverbal. Of those interviewed, 3 out of 3 residents denied the allegation, stating that staff change them on a regular basis, and they are never left wet for a long period of time. On 5/28/25, LPA reviewed staff training regarding care for incontinent residents, which indicates that they have knowledge of how to care for residents who are incontinent. Based on the information gathered, there is insufficient evidence to support the stated allegations Page 2 of 4 Allegation: Staff did not respond to resident’s calls for assistance The complaint alleges that R1 “called for assistance, and no one came.” On 5/28/25 at 11:56 am, LPA interviewed Administrator (A1) who denied allegation stating that "when resident called for assistance, there was a staff right there to assist R1." On 5/28/25, between 9:30am and 1:00pm, LPA interviewed 2 staff (S1-S2) regarding the allegation and (2) out of ( 2) staff denied the allegation stating R1’s needs were tended to when R1 called for assistance. On 5/28/25, between 1:00pm and 2:00pm, LPA interviewed 3 Residents (R2-R4) who denied allegation. (3) out of (3) residents stated that whenever they would call staff, they responded immediately. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff did not provide adequate food service to resident The complaint alleges that “during that time R1 was at the facility, R1 was only fed sandwiches” On 5/28/25, at 11:56 am, LPA interviewed Administrator (A1) who denied allegation stating they provide adequate food that is nutritious to the residents. On 5/28/25, between 9:30am and 1:00pm, LPA interviewed 2 staff (S1-S2) regarding the allegation and (2) out of (2) staff denied the allegation, stating that they serve adequate and nutritious food and that at no time was any resident served only sandwiches for a meal. On 5/28/25, between 1:00pm and 2:00pm, LPA interviewed 3 Residents (R2-R4) who denied allegation. (3) out of (3) residents stated that they are served nutritious food and they are never served "just sandwiches." Additionally, 3 out of 3 residents stated that they get enough to eat at the facility. On 5/28/25, between 11:00 and 12:00pm, LPA observed food service and the facilities food supply. LPA observed an ample supply of food for the residents in care. Page 3 of 4 Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above 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 allegations are UNSUBSTANTIATED . There were no deficiencies cited during today's visit. Exit interview conducted and report provided to Nelson Ortega, House Manager Page 4 of 4