complaint·April 28, 2026

Per observation, during investigation visits, LPA observed resident had a supply of diapers and under pads piled high on side of television next to wall across from R1’s bed. LPA observed incontinent supplies throughout resident’s room. Resident was left in soiled bedding for extended amount of time Per staff interviews, five of five staff stated that they were not made aware of R1 being left in soiled bedding for period of time. Staff interviews stated that R1 did need assistance with toileting and would be changed 3 to 4 times a day as well as checked on every two hours. Per witness interview, witness is aware of R1 needing assistance but does not know how often it is given at facility. Per R1 interview, R1 stated that on one particular occasion a staff member made them pee inside diaper and was left in soiled diaper for two days. Per observations LPA observed R1 to be comfortable during visits and R1 stated that they were not having the soiled issues as before. Per records reviewed R1’s physicians reports dated 4/23/22, 6/21/24 & 3/5/26 stated that R1 needs assistance with bathing, dressing and toileting due to their physical condition. Needs and Service Plan dated 6/20/25 states that R1 is total assist with bathing, grooming, dressing and toileting. Staff handled Resident roughly Per interviews, five of five staff stated that R1 never mentioned to them about being handled roughly by staff at facility. One staff member stated they were aware that R1 always requested about being handled “gently” while staff were providing care. Interview with R1 stated that a Care giver whose first name was provided shoved R1 against bed roughly and was rude. Interview with witness stated that R1 denied the allegation regarding staff, stating that R1 claims they were never pushed by a staff member, there was no abuse happening and that they felt safe at facility. Per observations, staff member whom R1 mentioned was not available for interview on 8/15/22 and was informed Staff member no longer works at facility and left back in 2022. LPA did not observe staff member on roster on 3/25/26. Per information gathered from investigation, the allegations Staff mismanaged toileting supplies, Resident was left in soiled bedding for extending amount of time and staff handled resident roughly were deemed UNSUBSTANTIATED meaning that although the allegations may have happened or are valid, there is no preponderance of evidence to prove that the alleged violations occurred as reported. An exit interview was conducted with Administrator Kathleen Tamondong, copy of report was discussed and provided.