complaint·April 28, 2026

Regarding the allegation, Resident has lack of care and supervision/ neglect, it is alleged that staff are not providing care and supervision to residents in care. During visits to the facility, LPA did not observe any lack of care and supervision/neglect. All residents were clean, well groomed, provided continent care, served meals, and actively engaged with staff. LPA observed all residents well groomed, with neatly combed hair. There were no residents screaming during the visit and LPA observed residents drinking fluids for hydration. Interviews were conducted and two out of three residents denied there being a lack of care and supervision/neglect, stating staff assist them throughout every day, often without being called to do so. One resident stated staff assist them with showers and grooming daily and additionally, as needed. Another resident stated they had to wait for care on one or two occasions but also stated “maybe they didn’t hear me calling them.” Five out of six staff denied the allegation, stating all staff are attentive and assist residents regularly and promptly. One staff stated, R1 is under hospice and requires assistance with their G-Tube and a Hoyer Lift. One staff stated during the tour, that hospice only comes once to twice a week and that the staff was trained by LVN from hospice to handle the G-Tube. Two out of two witnesses were not available for interview. Records reviewed for five out of five residents did not indicate any lack of care. Regarding the allegation, There is no staff present, it is alleged that on July 9, 2025, there was no staff present at the facility for a period of 30 minutes (from 6:22 AM to 6:54 AM) as the night staff left their shift early without ensuring the morning staff arrived to take over care for residents. During the investigation, five out of six staff denied the allegation, stating there has never been a time when staff were not present to assist residents in care. Two out of three residents stated staff are always present and they are not aware of a time where they were not. Resident 1 (R1) stated they called out for staff between 6:22 AM to 6:54 AM on July 9, 2026 and no one responded. The resident stated they do not recall what they needed at the time but they called for staff twice and no one answered or came to the room. Two out of two witnesses were not available for interview. A record review revealed, R1 has a G-Tube and continent needs, R2 has a colostomy bag and needs assistance with care, R3 needs total supervision per Physician’s report and wakes up at night per appraisal. Based on the observations made, interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the aforementioned allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Caregiver Rian De Leon, and a copy of this report was provided at exit.