Complaint·December 2, 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. The finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. The deficiency was previously cited on 11/25/2025 under complaint control #27-AS-20250507151513; therefore, no citation was issued. An exit interview was conducted with Executive Director, Corpus, and a copy of this report was provided to the facility. R1 was also interviewed and stated they have no concerns about going to the dining room for meals but occasionally prefer to eat in their room. R1 added that, in the past, it took staff longer to assist with transfers from bed to wheelchair; however, this issue has been addressed with Executive Director Corpus and is no longer a problem per R1. Based on R1’s needs and service, R1 requires minimal assistance with meals. Meal logs indicate that R1 has, on multiple occasions, declined to eat meals in the dining room. Moreover, during multiple unannounced facility visits, LPA Lee observed that R1 was either in the dining room for their meals or, if not, in their room having their meals. Based on records review and statement conducted during the investigation process LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director, Corpus, and a copy of this report was provided to the facility.