Complaint Investigation Report

Allegation #1: Staff left residents in soiled diapers for a long time.

This complaint alleges that residents go hours without being changed and remain in soiled and dirty diapers. On 12/03/2024, between 10:30 am -12:30 pm, LPA Richard interviewed seven (7) residents #1-7 (R1-R7). 6 out of 7of denied the allegation and stated that they are changed every one to two hours daily. LPA interviewed six staff #1-6 (S1-S6). 6 out of 6 denied the allegation and stated that all the residents are being changed every 2 hours, sometimes sooner if an accident happened before or after the time to change passed. LPA interviewed Administrator #1 (A1), who stated that the residents are checked every 1 - 2 hours. Record review of changing schedule (dated 11/01/24 to 11/30/24), has a schedule of all the name of residents who wears a diaper on when to be changed. LPA Richard attempted to interview R1, who declined to answer any of the questions asked.

Regarding the allegation: Staff leave residents soiled for an extended period, based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. As a result, the allegation is Unsubstantiated.

Allegation #2: Staff did not ensure that residents were fed.

This complaint alleges that staff did not ensure residents were being fed and not being woken up to eat. LPA interviewed Administrator #1 (A1), Maria Bravo, about the allegation. A1 stated that meals are served on the third floor at 8 am, 11:30 am, and 4:30 pm like clockwork. If a resident does not come to eat in the dining room, the staff would go and knock on the resident's door and ask if the residents want to have breakfast brought to the room. The Administrator stated that the staff serves a well-balanced meal with a variety of food options to choose from each day. On 12/03/2024, between 10:30 am - 12:30 pm, LPA Richard interviewed seven residents #1-7 (R1-R7). 6 out of 7 denied the allegation and stated that the facility would go to their room and knock on the door to make sure they had breakfast, lunch, and dinner in the dining room. They also stated that they did not have any problem with the food.