Complaint·November 25, 2025

Residents reported waiting from 30 minutes to several hours to be changed out of their soiled incontinence briefs. Moreover, according to R1’s LIC 602 Physician’s Report dated 09/02/2025, R1 requires assistance with toileting. A review of the facility’s “Past Events” call log showed response times ranging from approximately 30 minutes to three hours. Residents expressed that staff often take a long time to respond or, at times, do not respond at all when the pendant is pressed. Some residents reported leaving their rooms to find staff because their calls went unanswered. During an unannounced visit on 10/03/2025, LPA interviewed two residents, (R1 and R2) who expressed concerns about delayed incontinence care. On the same day, the LPA observed two residents press their call pendants and wait approximately 30 minutes without a staff response. While waiting, the LPA observed two care staff and two med-techs walking past the residents’ rooms, unaware of the pending calls. LPA Lee then notified the Executive Director, Ilona, regarding the residents who had been waiting. LPA confirmed that the call alerts appeared on the monitor at the front desk; however, there was no audible alert unless staff visually noticed the calls on the screen. Additionally, during multiple unannounced visits, LPA noted strong incontinence odors throughout the facility. Based on the statement conducted, records reviewed and observation during the investigation process LPA Lee was able to corroborate the allegation; therefore, the allegation that licensee does not ensure that there are enough staff to meet the needs of residents in care is found substantiated. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Executive Director Corpus and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. A review of records confirmed that R1’s topical cream is being administered as ordered, and that a PRN cream is either being administered and or refused by R1. Based on the statement conducted and records reviewed during the investigation process LPA Lee was unable to corroborate the allegation; therefore, the allegation that a resident developed a rash due to staff neglect is unsubstantiated. It was alleged that staff are mismanaging residents’ medications. The investigation included staff and resident interviews, as well as a review of facility records. During interviews, 7 out of 7 residents reported having no concerns regarding medication management by staff. R1 stated that they are receiving their medications and no longer have any concerns. Additionally, 5 out of 5 staff denied the allegations and confirmed that residents receive their medications according to the physician’s orders, with documentation recorded in the Medication Administration Record (MAR) or in the residents’ files. A review of R1’s MAR from March to November showed no discrepancies. During two unannounced facility visits conducted on 09/25/2025 and 11/17/2025, LPA Lee reviewed the medications for R1 and R2 and found no discrepancies. Based on the statement conducted and records reviewed during the investigation process LPA Lee was unable to corroborate the allegation; therefore, the allegation staff are mismanaging residents’ medications is determined to be unsubstantiated. 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. An exit interview was conducted with Executive Director Corpus and a copy of this report was provided to the facility.