complaint·February 5, 2026

Allegation: Staff do not ensure resident’s incontinence needs are met. The allegation alleges that during the night the caregivers do not check on them or change their diapers. During the facility inspection, LPA observed staff asking residents if they need to go to the restroom or if they need changed. During record review, LPA received and reviewed Resident R1’s Service Plan (dated 07/29/2025) that indicates R1 requires assistance with PM and nighttime incontinent care. LPA observed safety checks are to be done four (4) times per shift is listed as a Special Care Need. LPA received and reviewed Resident R1’s Physician Report (dated 09/30/2024) that comments patient requires assistance with toileting. Additionally, LPA received and reviewed Staff S2-S10 training records that indicate staff have received the following training on Relias within the last year, Restorative Nursing: Bowel and Bladder for the CNA, Managing Urinary Incontinent, and Care of the Bedridden Individual. LPA received and reviewed In-Service logs regarding Handling Residents with Care while Providing Incontinent Care, Peri Care, Toileting Log, and Incontinent Supplies. During interviews with Staff S1-S10, were asked how often residents are checked/assisted with changing briefs/diapers, ten (10) out of ten (10) stated they are checked/assisted every 30 minutes to two (2) hours depending on the residents. Additionally, Staff S1-S10 were asked if there was a time when they came into work and observed a resident in soiled diapers, seven (7) out of ten (10) stated no, they have not come into work and found a resident in soiled briefs/diapers. Three (3) out of ten (10) stated there was a time when they have come in and a resident was soiled, and they were informed during crossover, the resident at the time was refusing assistance with being changed. During interviews with Residents R1-R7, they were asked if there has been a time they were left in soiled diapers for an extended period of time, three (3) out of seven (7) stated no they have not been left in soiled diapers or briefs for an extended period of time. Two (2) out of seven (7) stated they had been left in soiled diapers for 5 to 15 minutes due to staff assisting other residents. Two (2) out of seven (7) stated they do not require assistance changing their briefs. Additionally, during interviews Residents R1-R7, were asked if staff check on them during the night to see if they need changed, five (5) out of seven (7) stated yes, staff come and check on them at night to see if their diaper or briefs need changed. Two (2) out of seven (7) stated they are not sure if staff check to see if they need changed at night. Allegation: Staff do not assist residents with repositioning. The allegation alleges that staff do not help a resident reposition for meals. During the facility inspection, LPA observed staff bring lunch to residents’ rooms. For residents who were having their meal in bed, LPA observed staff assist the residents up higher on the mattress before they raised the resident’s head. During record review, LPA received and reviewed resident R1’s Service Plan (dated 07/29/2025) that indicates R1 requires support with ambulation, mobility and repositioning. An added note states “Provide additional staff support to help with repositioning in bed. Additionally, LPA received and reviewed Staff S2-S10 training logs that indicate staff have received the following training on Relias within the last year, Assisting With Proper Positioning, Promoting Safe Eating, and Care of the Bedridden Individual. LPA received and reviewed In-Service training logs regarding Transfers/2 person assist and Rotating Bed Bound/Wheelchair Bound Residents. During interviews with Staff S1-S10, were asked if residents are assisted with proper positioning before receiving their meals, ten (10) out of ten (10) stated yes, they ensure the residents who are non-ambulatory or bedridden are positioned properly before eating meals. During interviews with Residents R1-R7, were asked if staff ensure they are positioned properly during meals, six (6) out of seven (7) stated yes staff ensure they are positioned properly. One (1) out of seven (7) stated they do not require assistance with positioning during meals. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated . During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Robert Jakini, and a copy of this report was provided.