Complaint Investigation Report

It was alleged that staff inappropriately sent the residents to the hospital. Interview conducted on 4/23/2026 at 12:00PM with facility administrator, revealed that resident #1 (R1) was brought to the hospital on 4/12/2026 at 4:10 PM to due to colostomy bags leak. Resident #2 (R2) was brought to the hospital on 4/12/2026 at 10:15 AM due to observation of maggots in R2’s stool and was discharged without conducting a stool check or laboratory exams.

Incident report revealed R1 was sent to the hospital due to colostomy bag was leaking and abdominal pain. Medical record review revealed R1 was discharge immediately and returned to the facility for colostomy care and gastritis. For R2, medical record revealed on 4/13/2026 at 8:25 AM, R2 was sent to the hospital again for abdominal pain and for laboratory exams. Medical records review revealed that R2 labs were eventually tested after the second visit on 4/13/2026. Interview with facility residents revealed that they are sent to the hospital when requested and necessary. Interview with staff revealed that residents are assessed first for their concerns and will be sent to the hospital when needed/ necessary.

Based on interviews and record review, there is insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Allegation: Staff did not ensure resident had colostomy bags.

It was alleged that facility staff did not ensure that resident #1 (R1) had supplies of a colostomy bag in the facility. Interview with residents revealed that the facility supplies all the residents' needs in the facility including colostomy bags for them and never runs out. Interview with administrator revealed no other residents in the facility uses colostomy bag. Record review and invoices revealed that the facility purchases R1’s colostomy bags every two (2) weeks on auto-ship each order includes 20 pieces. Interview with residents revealed that they have no issues with the facility supplying their needs. Interview staff revealed that if residents need supplies, a request is sent to the administrator, and the administrator provides the supplies for the residents.

Based on interviews, observation, and record review, there is insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.