Complaint·June 12, 2026

CW denied witnessing S1 breaking R1’s arm, nor did they witness any staff member having a physical altercation with any resident in care. CW did not know the last name of S1. LPA’s subsequent interview with CW did not reveal any additional information about injuries caused by S1 to any residents in care. LPA’s records review revealed that R1 passed away on November 21, 2022. LPA conducted an interview with business office manager (BOM), who stated that S1 was never employed by the facility, past or present. LPA’s records review confirmed BOM’s statement regarding S1. LPA conducted interviews with five (5) staff members, all of whom denied knowing S1 as their coworker. LPA conducted interviews with 14 residents, none of whom experienced rough handling or physical altercation by staff. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility did not report unusual incident to CCL. The complaint report did not contain any relevant information. LPA conducted an interview with a confidential witness (CW) for additional information, but CW did not provide any relevant information. LPA conducted interviews with six (6) staff members, all of whom stated that any unusual incidents are reported to medication technicians who then report to the management. The management then reports to the Department and keeps the incident reports for their record keeping. LPA observed past incident reports provided by business office manager (BOM) and confirmed the statements from the staff members interviewed. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility does not have enough food for residents’ daily nutritious needs resulting in weight loss. Information received indicated that the facility regularly runs out of food, and residents are losing weight due to missed meals. LPA conducted five (5) unannounced tours of the facility within a span of 7 days and observed that the facility had sufficient supplies of food for residents in care. LPA conducted interviews with 14 residents, none of whom experienced missing any of the three (3) daily meals. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interviews with six (6) staff members, all of whom denied the facility running out of food for residents. One (1) of the six (6) staff members interviewed stated that they have never witnessed the facility running out of food in the past 14 years. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. Continued on LIC9099-C.... It was alleged that staff do not assist residents with incontinence needs. Information received indicated that Resident #1, 2, 3, 4, and 5 (R1, R2, R3, R4, R5) were frequently observed in urine-soaked briefs. LPA conducted interviews with 14 residents, all of whom expressed their satisfaction with staff assistance. Of the 5 residents named, only 1 could be interviewed and that resident could not provide information. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interviews with six (6) staff members, all of whom stated that all residents receive two (2) hour room checks or more often if requested or necessary. LPA conducted tours of the facility but did not observe any concerns of neglect in incontinence care. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility and residents bathroom has mold. Information received indicated that three (3) residents’ bathrooms had black mold. LPA conducted interviews with 14 residents, all of whom denied witnessing mold in their bathrooms. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interview with six (6) staff members, all of whom denied witnessing mold in residents’ or common bathrooms. LPA conducted tour of the facility and inspected all residents’ and common bathrooms but did not observe a substance that could be mold in any bathrooms. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that staff do not shower residents. Information received indicated that Resident #6 (R6) did not receive a shower for four (4) days. LPA conducted interviews with 14 residents, all of whom stated that they have received two (2) showers per week, and staff have not missed any. LPA’s interviews with six (6) staff members confirmed the statements from the residents interviewed. LPA’s attempted interviews with seven (7) additional residents but were unsuccessful due to their cognitive condition. LPA’s attempted interview with R6 was unsuccessful due to lack of contact information. Request for shower logs was unsuccessful. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that staff do not change residents clothing. Information received indicated that residents wore the same clothing for days. LPA conducted interviews with six (6) staff members, all of whom stated that staff assist residents with clothing change every day, but most residents receive assistance with clothing change multiple times throughout the day after each mealtime. Continued on LIC9099-C.... LPA conducted interviews with 14 residents. Eight (8) residents interviewed stated that they did not need assistance with clothing change. Six (6) residents interviewed stated that staff have assisted with clothing change every day. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA’s observation during the resident interviews did not reveal any concerns regarding residents’ clothing change. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that facility does not have enough needed supplies to meet the residents needs. Information received indicated that the facility did not have enough incontinent, shower, or bedding supplies to meet the residents’ needs. LPA conducted interviews with 14 residents, none of whom experienced shortage of supplies for their needs. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interviews with six (6) staff members, none of whom experienced shortage of supplies in the facility. LPA toured the facility and observed cleaning and incontinent supplies. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. It was alleged that staff do not safeguard resident's personal property. Information received indicated that staff members use Resident #3’s (R3) shower supplies for other residents. LPA conducted interviews with six (6) staff members, all of whom stated that every resident has their own shower supplies stored in a container. LPA’s interviews with 14 residents and facility tour confirmed the statements from the staff members interviewed. During the tour LPA observed shower supplies in each room for each resident. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.