complaint·January 2, 2026

During today's visit, LPA obtained the following documents: staff and resident rosters. LPA interviewed the Care Coordinator and Resident #15 (R15). The investigation revealed the following: in regard to the allegation, “Staff do not ensure that resident's incontinence needs are met.” It is alleged that on 12/12/2025, R1 is supposed to have her incontinence supplies changed every two hours but R1 waited four hours to be changed. LPA interviewed one (1) out of 15 residents that corroborated with the allegation stating waiting for four hours for incontinence supplies to be changed when staff are supposed to change incontinence supplies for the resident every two hours. One (1) out of 15 residents corroborated with the allegation stated wait one hour and a half from the scheduled time to be changed. LPA also observed Resident #14 R14’s) room had a strong urine odor. Two (2) out of 15 residents interviewed could not confirm nor deny the allegation since they stated they do not require any incontinence supplies change from the staff. 11 out of 15 residents denied the allegation by stating that the staff meets their incontinence needs and they don’t have any problems. LPA interviewed the Executive Director, Care Coordinator and one (1) out of seven (7) staff corroborated with the allegation stated that there was a delay in providing incontinence change for residents on 12/12/2025 and the incontinence change service for R1 was provided at 9:15am which is two hours when it should have been done at the scheduled time of 7am. LPA interviewed Care Coordinator which stated that 40 to 48 residents out of the facility census of 147 residents required incontinence change service in the AM shift on 12/12/2025. Per Care Coordinator interview, there are normally five (5) caregivers on duty in the Friday AM shifts on which each caregivers are assigned 10 to 12 residents that need incontinence change service. LPA observed the staff schedule for 12/12/2025 and confirmed with the Executive Director and the Care Coordinator that there were two (2) caregivers calling off and one (1) caregiver off on vacation. Per Executive Director and Care Coordinator interview, there were only two (2) caregivers in the AM shift to provide incontinence change service for 40 to 48 residents which caused a delay in providing incontinence change service for residents on 12/12/2025. LPA interviewed the three (3) out of seven (7) staff that denied the allegation by stating that the care staff change the residents in a timely manner. LPA interviewed three (3) out of seven (7) staff that could not confirm nor deny the allegation since they are not involved in providing this service. Therefore, there was sufficient evidence to corroborate with the allegation. Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. An exit interview and a copy of the report and appeal rights were provided to Med Tech, Michael Yepez. During today's visit, LPA obtained the following documents: staff and resident rosters. LPA interviewed the Care Coordinator and Resident #15 (R15). The investigation revealed the following: in regard to the allegation, “Staff did not serve residents' meals in a timely manner.” It is alleged that on 12/12/2025, the facility served the residents breakfast from 7:00am to 8:30am. LPA interviewed one (1) out of 15 residents corroborated with the allegation stating that meals were served late from 7:00am to 8:30am on 12/12/2025. LPA interviewed 13 out of 15 residents denied the allegation stating that meals were served in a timely manner at 12/12/2025. However, one (1) out of 15 residents stated that meals are brought late and cold to the resident’s room. LPA interviewed the Executive Director, Dietary Director, and seven (7) out of seven (7) staff denied the allegation stating that meals were served on a timely manner on 12/12/2025. Dietary Director and two (2) out of seven (7) staff also stated that breakfast was served from 7am to 8am on 12/12/2025. LPA observed residents eating their meal at the dining hall during lunch time from 10:45pm to 11:30am during the initial visit on 12/18/2025. LPA also observed residents eating the following items: spaghetti with meatballs, cauliflower, lemon pudding, and beverage on 12/18/2025. LPA observed the dietary staff prepare the to-go meals at 10:40am and the care staff take the to-go meals to deliver to residents in their rooms at 11am on 12/18/2025. LPA observed that the meals were served in a timely manner on 12/18/2025. Therefore, there are not enough sufficient evidence to corroborate the allegation. Allegation: “Staff did not assist residents with showering.” It is alleged that on 12/12/2025, R1 did not receive shower assistance due to lack of staff. LPA interviewed 12 out of 15 residents denied the allegation stating on receiving shower assistance on 12/12/2025. However, one (1) out of 15 residents stated that shower assistance was received two hours after the scheduled time on 12/12/2025. One (1) out of 15 residents denied the allegation stating on receiving shower assistance from staff every Monday. Two (2) out of 15 residents could not confirm nor deny the allegation since they stated not receiving shower assistance LPA interviewed the Executive Director, the Care Coordinator, and three (3) out of seven (7) staff that denied the allegation stating that bathing assistance was provided to residents on 12/12/2025. One (1) out of seven (7) residents denied the allegation but stated that shower assistance was provided two hours after the scheduled time for one resident on 12/12/2025. Three (3) out of seven (7) staff could not confirm nor deny the allegation since they are not involved in providing this service. LPA reviewed resident shower logs that indicated that R1 and other residents have been receiving shower assistance as scheduled. Therefore, there are not enough sufficient evidence to corroborate the allegation. Based on statements and interviews conducted with staff, residents, review of resident 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 violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was held and a copy of this report was provided to the Med Tech, Michael Yepez.