Complaint·July 8, 2025

Per interviews, R1 was receiving incontinence assistance from S1. Interviews did not reveal that S1 used the same gloves and cloth to provide incontinence care to R1 after cleaning the floor. Internal and external interviews did not reveal that R1 is left in soiled incontinence briefs for extended periods of time. Review of R1’s physician’s report dated May 8, 2025, revealed that R1 could feed themselves but required assistance with all other activities of daily living, has bowel and bladder impairment and wears incontinence briefs. Review of R1’s resident assessment dated May 18, 2025, revealed R1 requires routine incontinence checks. Interviews verified this need for R1. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not meet resident’s incontinence care needs and staff did not follow Personal Protective Equipment (PPE) protocol when providing care to resident. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Resident Services Director Lizzie De La Fuente Mistica, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.