One of the staff interviewed directly changed R1 themselves prior to the appointment. Additionally, LPA was contacted by facility management prior to the incident, on 2/20/2025 regarding the situation. Management informed that Law Enforcement came to the facility to investigate the allegation and did not express any concerns regarding R1's care. Management informed that R1 was clean and dry prior to the appointment in question. Management also informed that R1 frequently refused to take their prescribed medication at the correct time, which would have prevented the frequent major incontinence episodes. Management informed that they had been trying to navigate this situation with R1 for some time, as they could not violate R1's personal rights by forcing R1 to take their medications; facility staff have been diligent with assisting R1 clean up after each incontinence episode.

Review of facility records did not corroborate the allegation. The records reviewed corroborated staff statements regarding the timeline of events the day of incident. Review of R1's Medication Administration Record (MAR) corroborated staff statements that R1 refused to take the prescribed medication at the recommended time, 11:00am, in order to prevent incontinence episodes. The MAR showed that during the month of February 2025 to present day, R1 refused to take their medication at the recommended time 23 (twenty-three) out of 27 (twenty-seven) times. The MAR showed that R1 consistently accepted the medication at 12:00pm, after they had eaten instead of before, which resulted in the major incontinence episodes. R1 accepted the medication at the recommended time 4 (four) out of 27 (twenty-seven) times. Additional facility records show documentation of R1's medication refusals at the recommended time and refusals to shower after having subsequent incontinence episodes. The records showed that R1 was assessed for skin issues, incontinence needs, and showered/groomed the day of concern and the day prior to the incident.

Outside source interviews did not corroborate the allegation. An outside agency involved with R1's care informed that R1 has presented to the agency for appointments soiled on different occasions, leading them to believe that the facility was not ensuring R1's incontinence needs were met prior to the appointments. However, the agency admitted that they did not reach out to the Licensee regarding their concerns and were not aware of R1's pattern of refusing the medications necessary to prevent the incontinence episodes. The agency admitted that they did not confirm if the facility had assisted R1 with incontinence care prior to transport, and an assumption was made regarding the facility not meeting R1's incontinence care needs. Requests to additional outside sources for interview were not returned. (Continued on LIC9099-C p.3)

LPA interviewed R1 privately during the visit. R1 informed that things were going well at the facility. R1 stated that staff assisted them with incontinence care when needed and helped them with hygiene care. R1 confirmed during interview that the Licensee was meeting all of their care needs.

LPA directly observed R1 during this unannounced facility visit. R1 was observed to be clean, groomed, and appropriately dressed for the temperature. LPA did not observe any health or safety issues for R1. Additionally, LPA has directly observed and spoken with R1 during previous facility visits for unrelated circumstances. During past visits LPA observed R1 to be clean, groomed, and appropriately dressed for the temperature. LPA has not observed any health or safety issues for R1 during previous facility visits.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.