Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff allows resident to be left in soiled clothing for extended periods of time. It is being alleged that R1 was observed with filthy and soiled clothing. It is also being alleged that R1 only has one pair of underwear. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said residents receive a change of clothing daily and as needed. 4 out of 4 staff said that resident who require incontinence care are changed every 2 hours, and as needed. 4 out of 4 staff said that R1 has more than one pair of underwear.

On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said staff had never left them in soiled clothing for an extended period of time. 6 out of 6 residents said they receive a change of clothing daily. 6 out of 6 residents said they own more than one pair of underwear.

On 09/03/25, LPA Gonzalez conducted a tour of the facility and inspected R1’s bedroom (#118). LPA observed the room to be clean, sanitary, and in good order. LPA observed clean clothing stored in R1’s drawer space, including more than one pair of clean underwear available for R1’s use.

Based on records reviewed, observation, and interviews conducted, there is insufficient evidence to support the allegation. 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, therefore the allegation is unsubstantiated.

Allegation: Resident sustained unexplained bruises. It is being alleged that R1 had red and purple bruises all over their arms and was walking in pain. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said that R1 has not sustained any unexplained injuries or unwitnessed falls. An interview with S1 revealed that they believe the spots on R1 are more like aging spots and not bruises.