Complaint·April 21, 2026

Regarding: Staff do not ensure resident's bed is in good repair. It is alleged that resident’s mattress was completely soaked and the bed was broken. It is also alleged that it was reported to staff, but staff have not done anything about it. Staff deny the allegation. Interviews with (11) out of (11) staff indicated that residents’ beds are in good repair and mattresses are monitored daily for cleanliness during wellness checks, incontinent care and housekeeping visits. Staff indicated that if beds are worn out, or become damaged, they are replaced immediately. Staff indicated that residents have not complained regarding having a broken bed or a soiled mattress. Seven (7) out of (11) staff indicated that mattresses are protected against spills with mattress covers which are cleaned and sanitized when they become soiled. Staff indicated that bedding is changed (3) to (4) times a week or as needed. Staff indicated that R1 puts extensive wear and tear on their bed and mattress during transfers; however, the facility has changed them out when needed. Staff further indicated that R1 has not complained about their bed being in disrepair or their mattress being soiled. Interview with R1 indicated that they have no concerns with the condition of their bed and mattress. LPA inspected (12) rooms (including R1’s) with (2) beds each and found the beds and mattresses to be in good repair. Beds had mattress pads, fitted sheets and were observed to be dry. Interview with (11) out of (11) residents indicated that their mattress and bed are in good condition and did not have concerns. Interview with R1’s Power of Attorney (P1) indicated that they visit R1 at the facility four times a week and has not observed any issue with R1’s mattress and bed. P1 indicated that R1 has worn out the mattress in the past, but facility staff changed it as soon as P1 requested it. P1 stated that during their visits, the mattress and bedding is clean and dry. P1 stated that R1 is doing well at the facility and staff are doing a good job in caring for R1. Staff and resident interviews, interview with P1 and LPA observations could not corroborate the allegation that resident’s mattress was completely soaked and their bed was broken. Regarding: Staff do not ensure resident's showering needs are being met. It is alleged that resident smelled badly and that resident had been asking staff to bathe them for one week and they would not do it. Staff deny the allegation. Interview with (8) out of (8) staff indicated that residents are bathed (2) times a week or more if needed. Staff indicated that R1 receives bathing assistance from staff; however, R1 sometimes refuses to bathe. Staff indicated that residents cannot be forced to bathe, but R1 is encouraged to do so (3) to (4) times during scheduled bath/shower days. ***Continues on LIC 9099-C page 2*** Staff further indicated that when R1’s declines to bathe, staff conduct a light sponge bath to prevent R1 from having body odor. R1 declined to talk to LPA regarding their bathing needs during interview; however, interview with R1’s POA (P1) indicated that R1 is clean and does not smell bad. P1 further indicated that staff meet R1’s showering needs as best as they can and do not force R1 to bathe. Eleven (11) interviewed residents indicated that they have no issue with their bathing needs. LPA reviewed R1’s Skin Integrity Monitoring Forms and found that R1 is receiving regular bathing assistance and attempts are documented when R1’s refuses their scheduled bath. Staff, resident and POA interviews and record review, do not corroborate the allegation that residents smells bad and that staff are not bathing resident when resident asks. Regarding: Facility is malodorous. It is alleged that resident’s room smells and the floor is sticky. Staff deny the allegation. Interviews with (11) out of (11) staff indicated that the facility is not malodorous. Staff indicated that residents’ rooms nor the common areas of the facility have bad smells or have sticky floors. Staff indicated that residents’ rooms and all common areas are cleaned regularly. Staff indicated that R1’ room is cleaned every day as scheduled by housekeeping staff and extra cleaning is conducted as needed. Staff indicated that R1 is visually impaired and at times may spill juice or milk on the floor, however, staff monitor R1’s room every hour to ensure spills are cleaned up if they happen. Interview with R1 indicated that their room is clean and they do not smell anything bad. Eleven (11) interviewed residents indicated that staff are cleaning their room and mopping their floor regularly. LPA inspected (12) resident rooms and did not observe floors to be unclean or sticky. During resident room checks and tour of the common areas, LPA did not sense foul odors. Interview with R1’s POA (P1) indicated that R1’s room is cleaned daily by facility staff and has no concerns regarding room smelling bad or floor being sticky. Interviews with staff, residents and POA and LPA observations could not corroborate the allegation that the facility is malodorous. ****Continues on LIC 9099-C page 3**** Regarding: Staff do not ensure facility is clean and sanitary. It is alleged that resident’s room is not cleaned on a regular basis. Staff deny the allegation. Interview with (9) out of (9) staff indicated that residents’ rooms and all common areas of the facility are cleaned regularly. Staff indicated that residents’ rooms are cleaned by housekeeping staff daily. Staff indicated that bedding is also changed (2) to (3) times a week but staff will check condition of resident bedding during incontinent care routine and will change it if needed. Staff further indicated that R1’s room is cleaned every day, and staff provide extra monitoring due to R1 being visually impaired and sometimes spilling their drink on the floor. Interview with R1 indicated that their room is cleaned by staff and did not express any issue with their room not being clean and sanitary. Interview with R2, R1’s roommate, indicated that their room is cleaned daily by staff and stated that all is well with their room. Interview with R1’s POA (P1) indicated that they visit R1 (4) times a week at the facility and R1’s room is always observed clean and sanitary. P1 further indicated that during P1’s visits to R1, they observed housekeeping staff clean R1’s room appropriately. During tour of the facility, LPA observed housekeeping staff cleaning resident rooms. LPA inspected 12 rooms, including R1’s, and observed the rooms and bathrooms to be clean. Common areas, hallways and outdoor areas were also observed clean. Ten (10) interviewed residents indicated that staff are cleaning their room and mopping their floor regularly. Residents also indicated that staff do a good job of cleaning their rooms. Staff, resident and POA interviews, and LPA observations do not corroborate the allegation that the facility is not clean and sanitary. Although the allegation may have happened or is 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 Jaqueline Cortez, Executive Director, and a copy of this report was provided.