complaint·February 5, 2026

Interviews with facility staff indicated that housekeeping staff are assigned by resident hall and by shift. Each hall (Hall 1, Hall 2, and Hall 3) has designated housekeeping coverage during the AM and day shift and in addition to a janitor. R1’s responsible party reported no concerns regarding R1’s room being unclean, unsanitary, or malodorous, and stated that R1 at times refuses housekeeping services. During visits conducted on 01/06/2026 and 02/05/2026, LPA Lee toured the facility, including multiple resident rooms, and did not observe any rooms to be unclean, unsanitary, or malodorous. On both visits, LPA Lee observed housekeepers assigned to each resident hall cleaning throughout the facility. During both visits, Room 317, occupied by R1, was observed to be clean and free of malodor. LPA Lee observed two plastic cups and tissues on the resident’s chair. It was learned that R1 prefers that the plastic cups and tissues not be discarded when housekeeping offers to remove them. Based on interviews and observations conducted during the investigation, LPA Lee was unable to corroborate the allegations. It was alleged that the staff do not ensure resident is capable of operating oxygen equipment. This investigation consisted of interviews with staff, the residents, the resident’s responsible party, direct observations, and a review of records. Based on interviews with facility staff, it was reported that the resident is capable of operating their oxygen and CPAP machines. Resident 1 (R1) stated that they know how to operate their oxygen and CPAP machines and reported no concerns regarding the allegation. R1’s responsible party also reported no concerns and stated that R1 is able to operate the oxygen and CPAP machines; however, they reported that R1 at times refuses to use the equipment and described R1 as “non-compliant.” On 01/06/2026, with Health Services Director (HSD) Flores present, R1 demonstrated the use of their oxygen and CPAP machines. R1 independently demonstrated turning the machines on and off and properly placing the oxygen tubing in their nose. Based on R1’s Individual Service Plan, R1 is capable of properly using the CPAP machine but at times declines due to low motivation. R1 also receives oxygen treatment, which is self-managed; however, R1 can occasionally be non-compliant with physician orders. Based on interviews and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.