Complaint Investigation Report

9099C-1... One staff stated there are less than (10) residents that need toileting help and they have not seen any issues, and commented that the facility is "understaffed on the weekends, especially on the "pm" shift which has less people". This staff added that the "am" shift has the best caregivers" and they are more consistent; whereas on the "pm" shift, residents have to wait longer due to 1.5 staff only". Another staff confirmed that residents will call for toileting assistance sometimes in between their scheduled incontinent checks and feels all staff "do a great job" commenting "we all are pretty prompt" ; however, stated the "pm" shift is overwhelmed and overall the facility is short staffed.

One resident (R1) stated to LPA on 10/24/25 (Friday) (3:30 pm) that they have not been provided with incontinent care since 8:00 am this morning when they woke up and a staff changed them. This resident confirmed they have pushed the pendant, but the facility is "short staffed on all shifts", asserting "they are supposed to change me (incontinent) four times per day" and provided LPA with the scheduled times and staff (S1) who always attends to them promptly, is off today, but usually brings them tomato juice in the morning. Staff schedules show (S1) works on the "am" shift, from Sunday through Thursday.

(R1) stated to LPA that no staff had come to check on them, including bringing water, since 8:00 am this morning, pointing to their bedside table. Within (5) minutes of LPA speaking to (R1), LPA observed (3) staff knock and enter the room to offer incontinent assistance and empty the trash.

Another resident (R2) stated t hey were not helped in the restrooms timely and complained a week ago Thursday, Oct 16, 2025, that there were "no caregivers on staff from 2:00 pm- 6:00 pm". This resident stated they "had an emergency" on the toilet and explained how they called the front desk and "no one answered" , until they told the Resident Services Director (RSD) and the Administrator, who brought them more toilet paper they were asking for. This resident also stated "no one answered the pendant" when they pushed it and added there are less staff on the "pm" shift, and staff are less trained" than the "am" shift.

Based on information obtained, LPA finds this allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.