Complaint·January 15, 2026

LPA interviewed S2 who remembered the meeting/education with the director, however, denied leaving resident in a wet bed full of urine or with briefs above their knees. S2 stated that he/she always made sure the residents are cleaned and S2 also stated that it is common for a resident to urinate right after they were cleaned and changed. LPA interviewed 4 other staff members and all of them reported that they have not witnessed residents sleeping in a wet bed full of urine or with briefs above the resident's knees from the previous shifts. During LPA's visit on 12/18/2025, LPA observed R1 appeared to be well groomed, cleaned and pleasant. LPA attempted to interview R1 but R1 did not remember staff not providing proper care. Based on record review, observation and interviews during the investigation, this allegation is deemed to be unsubstantiated as the director stated that she went to observed R1 after S1's reporting and she did not observed R1 was in the condition that was described by S1. In addition, the director stated that re- education was provided to S2 who denied the allegation. Furthermore, 4 out of 4 staff members stated that they have not witnessed residents sleeping in a bed full of urine or with the briefs above their knees. Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.