complaint·March 12, 2026

Staff 3 reported Resident 1 required at least two brief changes per shift due to urinary incontinence and occasionally required clothing changes when urine leaked through clothing. Staff 3 further stated Resident 1 experienced a period where more frequent incontinent checks were required, during which staff provided additional hygiene care including showers and clothing changes. Staff reported residents are routinely checked by caregivers because many residents are unable to effectively communicate their needs. Staff reported they did not believe any resident sits in urine movements for extended periods and stated staff would change residents when they are observed to be soiled. Based on interviews conducted and records reviewed, there was insufficient evidence to support the allegation that staff failed to provide proper diapering assistance to the resident. Therefore, the allegation is Unsubstantiated. Regarding the allegation that staff did not shower the resident, LPA conducted interviews with facility staff and reviewed the resident’s records. Staff reported residents receive showers according to their care plans and staff assist residents with bathing as needed. Staff reported the Resident 1’s care plan included scheduled showers and staff provided showers in accordance with the resident’s needs. Staff 3 reported Resident 1 occasionally experienced incontinent accidents and during those instances staff would shower the resident and change their clothing to maintain hygiene and prevent skin irritation. Staff reported Resident 1 may have received additional showers when hygiene needs required it. Although the allegation 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 allegation is unsubstantiated. Regarding the allegation that staff failed to wash the residents’ clothing, LPA conducted interviews with facility staff. Staff reported residents have designated laundry schedules and staff complete laundry services for residents according to the facility’s procedures. Staff stated Resident 1’s clothing was washed as needed and clothing was changed when the resident experienced incontinence episodes. Staff 3 reported Resident 1 occasionally required clothing changes due to urinary incontinence and staff would change the resident’s clothing and ensure the clothing was laundered as needed. Based on interviews conducted and records reviewed, there was insufficient evidence to support the allegation that staff failed to wash the residents’ clothing. Although the allegation 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 allegation is unsubstantiated. Regarding the allegation that staff failed to safeguard the resident’s personal belongings, LPA conducted interviews with facility staff. Staff reported Resident 1’s personal belongings are maintained in Resident 1’s rooms and staff assist residents with laundry and clothing changes as needed. Staff did not report any concerns regarding missing personal items belonging to Resident 1. Staff 4 stated the facility did attempt to address Reporting Parties concern by purchasing new items for Resident 1 even though there was not any evidence that items were actually lost. Based on interviews conducted and records reviewed, there was insufficient evidence to support the allegation that staff failed to safeguard the residents personal belongings. Although the allegation 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 allegation is unsubstantiated. Exit Interview conducted with Business Office Director, Brenda Velasquez, and a copy of this report provided.