Complaint·November 17, 2025

Allegation – staff did not ensure that residents were hydrated (con't): Through interviews with residents, they stated that they had access to water and fluids whenever they needed them. They described hydration stations placed throughout the facility, including in common areas like the movie theater and the café on the second floor. They also stated that staff were available to help if needed. Interview with a family member during a visit on 7/28/25, who visited their parent regularly, stated that they have never seen any issues with hydration. Interview with some staff acknowledged that the facility was experiencing staffing challenges, especially in the Memory Care (MC) Unit, but did not report any issues related to hydration. A report from an Ombudsman which they noted that one hydration was observed in the MC Unit but was missing cups and had damage to its surface. During a site visit by LPA Arielle Pascua and LPA Villanueva on 7/28/25, hydration stations were observed in both the Assisted Living (AL) Unit and MC Unit. LPAs observed water and other fluids being served to residents during lunch, and hydration stations appeared stocked and accessible during this visit. Based on interviews, record reviews, and observation, there is not enough evidence gathered to support this allegation. Therefore, the allegation was UNSUBSTANTIATED. ***************************************************** Allegation – staff did not meet resident’s incontinence needs: The investigation into this allegation consisted of interviews with staff and residents, reviews of relevant records and site visit to observe care practices. Additionally, statements and interviews from residents’ family members were reviewed. Residents interviewed reported that staff responded quickly to call buttons and helped them with toileting and bathing when needed. None of the residents that were interviewed expressed concerns about being left in soiled clothing or not receiving help. One family member of a resident stated that they had no complaints and believed the facility as well-staffed and attentive to residents’ needs. Statement from another family member expressed contradiction and reported that their parent was not changed between 8am and 1:30pm on 5/21/25. They also claimed that routine incontinent brief changes were missed due to staffing shortages in the MC Unit. Staff interviews revealed staffing was inconsistent, especially in the mornings, and that staffing agency workers were being used to fill gaps. Memory Care Director also confirmed providing direct care to residents due to staff shortages. {2 of 3} Allegation – staff did not meet resident’s incontinence needs (con't): During LPAs Pascua and Villanueva’s site visit on 7/28/25, staff were observed assisting residents during lunch, and no signs of neglect or hygiene issues were noted at this visit. LPAs also observed outside agency staff were working during this shift. While staffing issues were evident, there is not enough consistent evidence to prove that residents’ incontinent needs were being neglected. Therefore, the allegation is UNSUBSTANTIATED. ***************************************************** Allegation – staff did not assist residents with bathing: The investigation into this allegation included interviews with sample residents, staff, and family members, reviews of reports, and site visit to observe care practices. The residents that were interviewed stated that they receive help with bathing when they asked for it. One resident mentions that they are mostly independent, but staff are available when assistance is requested. Another resident confirmed that staff usually help with bathing and toileting. None of the residents interviewed reported being denied help or left unattended. During a site visit on 7/28/25, a family member, who was visiting a resident, stated that they had no concerns and believed the facility was meeting their parent’s needs. A statement from another family member did not mention bathing from their statement but did express concerns about staffing shortages and general neglect in the MC Unit. Staff interviews and based on Ombudsman's reports confirmed that facility was experiencing staff issues. Memory Care Director have reported that they sometimes help with resident care. During LPAs Pascua and Villanueva's site visit on 7/28/25, they observed both AL and MC units. No signs of poor hygiene or missed bathing care were noted during this visit. LPAs also observed outside agency staff were working during this shift. Although staffing issues were reported, there is insufficient evidence to show that staff did not assist residents with bathing. Therefore, the allegation is UNSUBSTANTIATED. Note that unsubstantiated findings mean that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. No citations are being issued at this time. An exit interview was conducted with AD and a copy of this report and appeal rights were provided upon exit. {3 of 3}