Complaint·March 20, 2026

Regarding the allegations, “Staff left residents in soiled diapers too long, causing a rash,” “Staff did not clean resident rooms,” and “Staff did not provide proper medication assistance,” LPA interviewed four staff members and four residents, all of whom denied the allegations. During the facility walk-through, LPA did not detect any incontinence odor from the residents interviewed. LPA also reviewed the facility’s Shower Body Check Forms, which showed that residents requiring bathing assistance were scheduled to bathe twice per week. These forms also required caregivers to document any rashes or bruising observed on residents. None of the forms reviewed contained documentation of any rashes. LPA interviewed four staff members who stated that the facility employs both housekeeping and maintenance staff to clean resident rooms and common areas. Staff reported that housekeeping personnel clean resident rooms, bathrooms, and common areas daily, with additional cleaning completed as needed. LPA also interviewed four residents, all of whom stated that their rooms are cleaned regularly and that they had not observed any unclean rooms. In addition, LPA reviewed three random Medication Administration Records (MARs) for selected residents. The records reflected accurate and timely medication administration. LPA also observed the facility’s medication administration process during the visit. During this observation, LPA noted that Medication Technicians verified each medication against the resident’s name, dosage, and photograph before dispensing. Regarding the allegation, “Staff are not properly trained,” LPA reviewed staff records and training documentation maintained by the facility. The records showed that staff had completed the required training relevant to their assigned duties. For example, all Medication Technicians had completed the required annual eight-hour training, and caregiver staff had completed mandatory training provided by the facility. LPA also interviewed four staff members, who stated that they had received training from the facility and understood their responsibilities related to resident care and supervision. LPA further interviewed four residents, none of whom reported concerns indicating that staff were untrained or unable to perform their duties. Regarding the allegation, “Staff failed to properly supervise residents, resulting in falls,” LPA reviewed four random residents' incident reports related to falls. The records reviewed did not reveal evidence to show that falls occurred as a result of staff neglect or lack of supervision. {***CONTINUE9099C***) LPA interviewed four staff members, who stated that residents are monitored and assisted based on their individual care needs and that falls are documented and addressed when they occur. LPA also interviewed four residents, none of whom provided information supporting the allegation that staff failed to properly supervise residents, resulting in falls. Based on the investigation, there was insufficient evidence to prove that the alleged violations occurred. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Case Manager (CM) April Pena.