complaint·November 4, 2025

R1 confirmed they went to the hospital multiple times due to their catheter leaking, which needed to be replaced. R1 also stated once the catheter was replaced there were other issues with their catheter, and they had to return 3 days in a row to the hospital for catheter assistance. R1 wore briefs in addition to the use of the catheter. R1 confirmed their briefs were being changed by staff and their urine bag was emptied. R1 stated their incontinent care needs were met by the facility staff. Facility staff interviews confirmed they applied ointment provided by R1’s nurse, changed R1’s briefs and emptied R1’s urine bag. Staff also explained that due to the catheter leaking, the urine would leak into R1’s diaper. However, staff changed R1’s briefs on regular basis. Staff also stated they changed R1’s briefs, 15 times in one day, to ensure R1 stayed dry due to the leakage from the catheter. It was also alleged that staff did not treat a resident with dignity. It was reported staff were mean to R1, called resident names and told R1 they won’t help R1 anymore. R1 denied the allegation and stated staff treated them well and were very attentive to R1’s needs. Staff explained one day R1 returned to the facility from the hospital. That day, R1 needed a brief change upon return. However, staff told R1 to wait, as the other caregiver was about to arrive at the facility to assist. R1 required a 2-person assist for safety reasons. Staff stated the facility has a Hoyer lift but R1 refused to use it. Therefore, the other staff were needed. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Rowena Ramos whose signature below confirms receipt of these rights.