Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff did not adequately address a change in resident’s condition.

It was alleged the resident had not been acting like themselves for several days and that the resident's urine had a strong, unpleasant odor, which are symptoms consistent with a urinary tract infection. It was further alleged that facility staff failed to notify the resident's healthcare provider of the observed changes in condition, despite the healthcare provider being the resident's primary care coordinator.

On 03/24/2026 between the hours of 10:20am - 10:30am, the department interview the Administrator (A1) in regards to the allegation.A1 denied the allegation. A1 stated the facility had no prior knowledge of any change in the resident's condition before 03/20/2026, as the resident was at her normal baseline and did not present with any symptoms of concern. A1 mentioned on the evening of 03/19/2026, the resident's family informed a MedTech that the resident had a UTI and would take the resident for evaluation. A1 stated the facility was not aware of a confirmed diagnosis until after the resident was seen by Welbe Health and that the family had already contacted Welbe directly. A1 stated the facility's protocol for a suspected UTI is to request a urinalysis from the appropriate medical professionals and follow all guidance provided, including medication administration.

On 03/24/2026 between the hours of 9:25am -10:18am, the department interview 3 staff in regards to the allegation.

3 out of 3 staff denied the allegation. Staff stated they did not observe or receive notification of any change in the resident's condition prior to 03/20/2026 and that Welbe Health was not notified because no change in condition had been identified. Staff stated the facility's protocol when a change in condition or suspected UTI is identified is to report to the MedTech, who is then responsible for notifying the healthcare provider.

On 03/24/2026 between the hours of 10:36am - 11:43am, the department 10 residents in regards to the allegation

1 out of 10 residents confirmed having a UTI but was unable to confirm how the facility staff addressed this situation. R1 recalled not feeling like themselves and noticing changes around 03/20/2026, and understands that their family member is the POA. 8 out of 10 Residents denied the allegation and stated staff respond to their medical needs in a timely manner. 1 out of 10 Residents did not confirm nor deny the allegation and stated staff do not respond to medical needs in a timely manner and that there has been a time when a request for medical help was not followed through.

On 04/02/2026, between the hours of 9:45am – 1:54pm, the department corresponded with Witness 1 (W1) in regards to the allegation.W1 confirmed the allegation. W1 stated that behavioral changes were first observed on 03/18/2026 by R1's private caregiver and that facility staff were notified of concerns regarding a possible UTI on 03/19/2026. W1 stated the facility took no action, did not notify Welbe Health, and that the family themselves transported the resident to Welbe Health on 03/20/2026, where the resident tested positive for a UTI.