Complaint Investigation Report

On the allegations: Licensee does not ensure that residents are provided with an adequate supply of hygiene items while in care. It was alleged that on multiple visits a witness observed residents in the memory care unit without toilet paper in their restrooms and in some instances with the toilet paper holder removed. During an initial visit on 6/23/25, LPA toured 18 out of 21 restrooms and found that each room except one (1) had toilet paper, all rooms had a toilet paper holder. LPA also toured the 2 restrooms that are used by staff and if needed residents, and all restrooms had toilet paper. LPA interviewed two staff who stated they provide toilet paper to residents, but there are times when a resident who is able to use the restroom unassisted uses their toilet paper and staff do not know until they check on the resident. Prior Staff member via a phone conversation stated that caregivers are to check the toilet paper at minimum when emptying the trash which is done on each shift.

The interview with maintenance staff stated they have extra toilet holders on hand due to residents, especially in the memory care unit, mistaking the toilet role holder as a grab bar and pulling the holder off the wall. Staff stated they have never been asked to remove a holder but does know there are times the brackets remain after the holder has been pulled off the wall. Maintenance staff was asked are you having any plumbing issues on the memory care side, staff stated no. At this time all staff interviewed stated they do not have residents with behaviors that are causing them to clog the toilets so no toilet paper is being withheld for that reason.

On return visit of 7/2/25, LPA again toured 21 out of 21 resident restrooms in the memory care unit and the two (2) staff/public restrooms and found that all restrooms besides one (1) had toilet paper on the toilet roll holder, the one (1) room with it not on the holder, the toilet paper, and the toilet roll insert were on the counter, accessible to the resident if need. LPA also looked under approximately 10 sinks where staff stated extra toilet paper from family is stored. Some residents did not have additional supplies; staff were able to explain that there are four (4) residents having behaviors with toilet paper on occasion and therefore some families ask the director to keep the supply in the medication room. A pack of toilet paper was observed by the LPA in the medication room.