Complaint·December 4, 2025

LIC 9099-C Interview conducted with resident (R1) revealed that staff are "good at changing" in the day but if an incontinence accident occurs in the middle of the night, staff does not respond for changing. R1 stated this typically occurs around midnight and staff will assist with changing around 7:00 AM. Interview conducted with resident (R3) revealed that incontinence care at night does not exist. R3 stated R3 requires full assistance with incontinence care by staff, last depend change occurs after dinner around 5:00-6:00 PM. R3 reported no assistance is available around 8:30 PM. Interview conducted with resident (R4) revealed that there have been multiple occasions where R4 soiled themselves in the middle of the night. R4 stated R4 tries to use call lights at night for emergencies only since staff are sleeping, but majority of the time, staff does not wake up to the call light as it is located in the kitchen away from the staff room which is separated by a fire door. Interview with R4 further revealed that there was a night where call light was triggered approximately at 10:00 PM but staff did not wake up to the call so R4 was left sleeping in wet depends which leaked to the bedding until morning. R4 stated recently it has been one caregiver working at the facility, with one caregiver working periodically on-call, when the facility used to be staffed with two caregivers working at all times. Based on the information obtained, the allegations are SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegations cited above are substantiated, please see LIC9099-D. Exit interview conducted and a copy of the report and appeal rights was provided.