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 was not cited since it was already cited on complaint control #27-AS-20250507151513. An exit interview was conducted with Executive Director Corpus and a copy of this LIC 9099 report was provided to facility.