complaint·January 29, 2026

Review of R1's medical assessments and needs and services plans dated 2025 and 2026 revealed that R1 was diagnosed with a major neurocognitive disorder (NCD), resulting in issues with disorientation, hazard awareness, impulse control, and expressions of frustration. Additionally, R1 was incontinent of bowel and bladder and required staff assistance with bathing, grooming, and toileting. R1 was also receiving hospice services for the major NCD diagnosis. Interviews revealed that R1 was often confused and unable to provide specific details regarding dates and times. Interviews with staff and outside sources revealed that in January 2026, R1 reported that an individual entered R1's room and hit them in the face, resulting in bruises. Interviews with staff and outside sources, as well as LPA observation, revealed that the individual R1 described did not fit the description of any staff working at the facility. Additionally, those interviews did not reveal any evidence of the existence of any bruising on R1 since R1's admission to the facility. During today's visit, LPA did not observe any bruising, cuts, or other injuries on R1's face or hands. Additionally, R1 denied that any individual had hit, cursed, or yelled at R1 while living at the facility. An outside source stated that they believed that R1 was extremely confused or experiencing hallucinations when they made the allegation. Interviews with residents, including R1, did not reveal any concerns regarding staff assistance or interactions and residents stated that staff were nice and helpful. Interviews with staff revealed that all residents at the facility wore incontinence briefs and required staff assistance with toileting, brief changes, showers and bed-bath services. Staff stated that a couple residents were able to let staff know when they required brief changes, and staff would check on residents every two hours for brief changes. Interviews revealed that for residents in bed, staff would place incontinence pads beneath residents to catch any possible leaks from the resident's incontinence brief. Staff denied putting two briefs on any residents, and stated that some residents would be checked and changed more often than every two hours. Additionally, staff stated they provided toileting and brief change assistance to residents multiple times overnight. Interviews with outside sources and residents did not reveal any concerns regarding incontinence care, or any other type of care and supervision provided by facility staff. Those interviews also did not reveal any evidence that any residents had been placed in two briefs. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Caregiver Arlan Acosta, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).