Complaint Investigation Report

Allegation #5: Staff did not ensure resident was cleaned during diaper changes.

LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that staff assist residents with diapering and ensure diapers are changed every two hours or as often as needed based on individual needs. 4 out of 4 staff members confirmed that proper hygiene practices are followed during diaper changes, including cleaning the resident before applying a new diaper. 4 out of 4 staff members stated that staff do not instruct residents to urinate in their diapers. 4 out of 4 staff members stated that residents are not left in soiled diapers for extended periods and do not exhibit a foul odor. S1–S4 denied the allegation.

LPA also interviewed residents #2–6 (R2–R6). One resident (1 out of 6) stated that staff change their diapers regularly and th at they are never left in soiled diapers. 1 out of 6 residents stated that staff cleans them appropriately during diaper changes. 4 out of 6 residents stated that they do not wear diapers and are independent in their toileting needs. R2 denied the allegation.

During the visit, LPA observed staff performing diaper changes during the visit and noted that staff followed proper hygiene protocols, including cleaning the resident before placing a new diaper. No evidence was observed to support the allegation.

Allegation #6: Staff did not serve an adequate amount of food to residents in care.

LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that residents are served an adequate amount of food. Staff confirmed that residents receive three meals per day plus snacks and have access to an ample supply of both perishable and non-perishable food items. 4 out of 4 staff members explained that residents are provided with more than enough food and are allowed second servings. If a resident does not like what is being served, alternative options are available. S1-S4 denied the allegation.

LPA observed residents eating lunch during the visit and verified that the facility’s food supply was sufficient. The observed meal included generous portions, and staff followed the posted menu. LPA also reviewed the facility’s food menus from May 2025 through July 2025 and confirmed compliance with meal planning requirements. See continued LIC9099-C page 5.