Complaint Investigation Report

Allegation – staff did not ensure that residents were hydrated (con't):

Through interviews with residents, they stated that they had access to water and fluids whenever they needed them. They described hydration stations placed throughout the facility, including in common areas like the movie theater and the café on the second floor. They also stated that staff were available to help if needed. Interview with a family member during a visit on 7/28/25, who visited their parent regularly, stated that they have never seen any issues with hydration. Interview with some staff acknowledged that the facility was experiencing staffing challenges, especially in the Memory Care (MC) Unit, but did not report any issues related to hydration.

A report from an Ombudsman which they noted that one hydration was observed in the MC Unit but was missing cups and had damage to its surface. During a site visit by LPA Arielle Pascua and LPA Villanueva on 7/28/25, hydration stations were observed in both the Assisted Living (AL) Unit and MC Unit. LPAs observed water and other fluids being served to residents during lunch, and hydration stations appeared stocked and accessible during this visit.

Based on interviews, record reviews, and observation, there is not enough evidence gathered to support this allegation. Therefore, the allegation was UNSUBSTANTIATED.

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Allegation – staff did not meet resident’s incontinence needs:

The investigation into this allegation consisted of interviews with staff and residents, reviews of relevant records and site visit to observe care practices. Additionally, statements and interviews from residents’ family members were reviewed.

Residents interviewed reported that staff responded quickly to call buttons and helped them with toileting and bathing when needed. None of the residents that were interviewed expressed concerns about being left in soiled clothing or not receiving help. One family member of a resident stated that they had no complaints and believed the facility as well-staffed and attentive to residents’ needs. Statement from another family member expressed contradiction and reported that their parent was not changed between 8am and 1:30pm on 5/21/25. They also claimed that routine incontinent brief changes were missed due to staffing shortages in the MC Unit.

Staff interviews revealed staffing was inconsistent, especially in the mornings, and that staffing agency workers were being used to fill gaps. Memory Care Director also confirmed providing direct care to residents due to staff shortages.