complaint·February 12, 2026

LPA interviewed the Administrator, three (3) out of three (3) staff that denied the allegation stating that they always change the residents if the briefs are soiled and check on them at least every two (2) hours. The Administrator and three (3) out of three (3) staff stated that when residents press their pendants and request a diaper change, staff will change them right away. Staff also stated they change the bed pads and ensure the residents are clean and dry. Per Administrator, two (2) out of three (3) staff indicated that there are two (2) caregivers on duty per shift to provide incontinence care for 11 residents out of the facility census of 70 residents. Two (2) out of three (3) staff stated that there are times when the staff are providing two (2) person assist on changing a resident, this may cause a delay in changing and/or helping another resident. However, one (1) out of three (3) staff stated that Med-Techs help assist the caregivers with providing incontinence care for residents. LPA interviewed R1 that corroborated with the allegation stating that R1 is kept wet and whenever R1 pushes the call button for help to change R1’s diapers, the staff do not check or change R1’s diapers. However, during the visit when the LPA met R1, LPA observed to time the staff’s response to the resident’s call button, R1 pushed the call button at 10:48am and the care staff arrived to help the resident at 10:49am. R1 also stated that the staff change R1’s diapers three times per day but there were times when R1 was changed only once in a day. LPA interviewed four (4) out of five (5) residents that receives incontinence care from the staff denied the allegation by stating that their incontinence needs are met by staff changing them frequently and never ran out of incontinence supplies and wipes. Four (4) out of (5) residents stated that there can be times when there is a delay and wait from five (5) minutes to one (1) hour to be changed. However, four (4) out of five (5) residents stated that the staff does change their diapers throughout each day, kept dry, and are not kept wet. Four (4) out of five (5) residents stated that they understand that when staff are helping another resident, there can be a delay but stated that most of the time the residents wait for a short time and longer wait times does not occur frequently. LPA attempted to interview an additional one (1) resident that receives incontinence care but was unable interview that resident since the resident could not answer the LPA’s questions. LPA interviewed an additional two (2) residents that could not confirm nor deny the allegation since they only receive incontinence supplies from the facility and change their diapers by themselves. However, those two (2) residents stated that the facility always provides them with the incontinence supplies. Those two (2) residents also stated that whenever the facility ran out of the incontinence supplies, the staff immediately re-stock and provide incontinence supplies to them on that same day. LPA took a tour of the facility and observed that there were sufficient incontinence supplies and wipes. LPA also observed that the bedrooms of the six (6) out of six (6) residents that received incontinence care were free of odors from incontinence. [Continue to LIC9099-C] LPA reviewed the facility’s Shift to Shift Report which notes routine two (2) hour checks and which residents’ diapers were changed. LPA reviewed Staff training on Incontinence Care dated 08/22/2025. There is not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations 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. An exit interview was held, and a copy of this report was provided to the Administrator, Bryanna Luke.