Complaint·January 29, 2026

Two out of the five residents interviewed stated that they do not require assistance with incontinence care. The Department conducted four staff interviews. Four out of the four staff interviewed confirmed that R1 was receiving assistance from the facility with incontinence care. Staff interviewed stated that the facility would put two diapers, and a liner on R1 at night for her incontinence issues, since the facility does not provide awake staff overnight. However, three out of the four staff interviewed stated that there were incidents in which R1 was soiled in the morning since she was not being changed overnight. Regarding the allegation, licensee did not ensure suppositories are administered by resident or an appropriately skilled professional, the following has been concluded: It was alleged that the licensee did not ensure suppositories were administered to R1 by an appropriately skilled professional. The Department was unable to conduct an interview with R1 for this allegation due to R1 passing away on November 12, 2024. The Department reviewed R1’s Physician Report dated March 28, 2024, which stated that R1 was unable to administer her own prescription medications. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that suppositories were administered by R1’s hospice agency. The Department reviewed R1’s medication administration records. The Department observed that R1 was administered a suppository on April 7, and July 16, 2024. The Department reviewed R1’s hospice visitation log and observed that R1 was visited on July 16, 2024, but was not visited on April 7, 2024. Therefore, a suppository was administered to R1 on April 7, 2024, without an appropriately skilled professional present. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegations that, facility staff do not properly assist resident with toileting needs overnight and licensee did not ensure suppositories are administered by resident or an appropriately skilled professional. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D pages. An exit interview was conducted via telephone with Administrator Leah Fajardo. A copy of the report and Appeal Rights were provided to an authorized facility representative. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that call buttons have always been available and within reach of residents. Due to conflicting information received during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted via telephone with Administrator Leah Fajardo. A copy of the report was provided to an authorized facility representative.