It is alleged that staff leave residents in soiled diapers for extended periods of time. It is also alleged that resident sits in a soiled diaper in the dining room and staff leave resident there.

Staff deny the allegation. Interviews with Staff 1 – Staff 7 (S1-S7) revealed that staff do not leave residents in soiled diapers for extended periods of time. Staff indicated that residents who require full incontinent care are checked routinely, every two hours or more if needed. Staff indicated that residents who are taken to the dining room by staff ensure residents’ diapers are checked and changed before taking them to eat. Staff stated that R2 has soiled their diaper while eating in the dining room; however, staff immediately return resident to their room and proceed to get them cleaned up. Interviews with (9) out of (10) residents indicated that staff assist with incontinent care in a timely manner and do not have concerns about how staff are conducting their checks. Interview with R2 revealed that staff change their diaper as soon as it is needed. LPA observed the breakfast and lunch meal services and noted caregivers doing wellness checks on residents in the dining rooms. Interviews and observations do not corroborate the allegation that staff do not ensure that residents’ incontinent needs are met.

Staff do not maintain facility in good repair.

It is alleged that toilet in resident room does not flush and resident has to lift up the toilet top and manually flush it. It is also alleged that many other residents’ toilets are in disrepair.

Staff deny the allegation. Interviews with (7) out of (8) staff indicated that resident toilets are not in disrepair. Staff indicated that residents have not reported having toilets in disrepair. Staff stated that maintenance staff conduct regular monitoring of the physical plant and if a disrepair is observed, staff inform maintenance personnel as soon as possible to ensure repairs are conducted in a timely manner. LPA toured the facility and inspected (10) resident and (2) staff bathrooms and found the toilets to be operational. LPA inspected the toilet in the room mentioned in the report and found it to be operational. When LPA interviewed the (2) residents who live in the room with the toilet allegedly in disrepair, they indicated that the toilet has always been operational and has not presented any issues to the residents. Further interviews with (9) out of (10) residents indicated that their toilets are operational and have not caused any issues. Interviews and observations could not corroborate the allegation that staff do not maintain the facility in good repair.

***Continues on LIC 9099-C page 2***

It is alleged that resident urinate in the television room and the room smells like urine.

Staff deny the allegation. Interviews with (8) out of (8) staff revealed that residents do not urine in the television room nor does it smell like urine. Staff indicated that the physical plant is regularly monitored to ensure cleanliness. Staff stated that the television room is cleaned daily and that residents have not reported smelling urine. Interviews with (9) out of (10) residents indicated that they have not observed residents urinating in the television room. Interview with R3 indicated that they have never urinated in the television room. Residents also indicated that they have not smelled urine in the television room. LPA inspected the television room and did not smell urine or any other foul odors. The television room was observed clean, and seating was free of odors and stains. LPA also observed throughout the facility, odor neutralizing spays which were working properly. Interviews and observations could not corroborate the allegation that staff do not maintain the facility sanitary.

Regarding: Staff do not allow residents to visit privately with licensing.

It is alleged that when licensing staff visit the facility, staff follow the licensing analysts around to prevent residents from speaking to licensing.

Staff deny the allegation. Interview with (8) out of (8) staff indicated that staff do not follow licensing analysts around to prevent residents from speaking to them. Interview with S1 who facilitates visits from licensing analysts indicated that analysts are accorded privacy with residents during their visits. S1 indicated that analysts are provided with access to the facility’s conference room to conduct their interviews in private. S1 indicated that a resident reported recently that a staff member was standing too close to the door of the room, which was closed, and in which an analyst was conducting interviews on 6/18/2026. S1 stated that a staff member was observing a small crowd that gathered outside of the conference room as they waited to talk to licensing, only to provide care and supervision of the residents and to ensure that the hallway had clearance for other residents to walk safely around the crowd. During today’s visit, LPA conducted interviews by visiting residents in their rooms and staff did not impede LPA from talking privately to staff and residents. LPA also worked in the conference room and staff knocked before entering. Interviews with (9) out of (10) residents indicated that staff do not prevent them from talking to licensing or other agencies privately. Residents further indicated that they have no concerns about being able to talk privately to fellow residents, staff or other agency representatives. Interviews and observations do not corroborate the allegation that staff do not allow residents to visit privately with licensing. ***Continues on LIC 9099-C page 3***

It is alleged that the TV room smells like urine which is not cleaned up by staff.

Staff deny the allegation. Interviews with (8) out of (8) staff indicated that the TV room does not smell like urine. Staff indicated that the physical plant is regularly monitored to ensure cleanliness. Staff stated that the television room is cleaned daily and that residents have not reported smelling urine. Interviews with (9) out of (10) residents indicated that they have not observed residents urinating in the television room. Staff also indicated that they have not smelled urine in the television room. LPA inspected the television room and did not smell urine. The television room was observed clean, and seating was free of odors and stains. LPA also observed throughout the facility, odor neutralizing spays which were working properly. Interviews and observations could not corroborate the allegation that the facility is malodorous.

Regarding: Staff do not provide a safe environment for residents in care.

It is alleged that sometimes the television room has a specific capacity; however, staff allows too many residents to be in the room at one time, resulting in in overcrowding.

Staff deny the allegation. Interviews with (8) out of (8) staff indicated that the television room is never overcrowded. Staff indicated that overcrowding has never been a concern due to only small number of people who visiting the television room. Staff stated that the room is typically observed to be used by five residents or less at a given time. Staff stated that the room is used more frequently in the evenings; however, crowds are always small and have not posed a safety concern. Interviews with (9) out of (10) residents indicated that the television room is never crowded and that they can safely spend time watching television. During today’s visit, three people were observed reading in the television room at different times by LPA. The television room has three doors and exits signs are clearly visible. No overcrowding was observed and exits were free of obstruction. Wheelchair access is available and there is sufficient space to house a crowd of about 10-12 people. Interviews and observations do not corroborate the allegation that staff do not provide a safe environment for residents in care.

Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Alisa Dean, and a copy of this report was provided.