Complaint Investigation Report

The allegation of “Staff left resident in soiled diapers/clothes for an extended period of time.” alleges that resident #1 (R1) was left in soiled diapers overnight between the approximate hours of 07:00 PM and 07:00 AM. LPA interviewed R1 who stated that for five (5) nights during their stay at the facility they were not changed in the evening by staff. R1 confirmed that they never asked Staff #1 (S1) for assistance with changing at night due to being instructed by the Administrator not to bother staff after 7:00 PM. LPA interviewed S1 who confirmed that R1 never asked for assistance with being changed in the evening during their stay at the facility. LPA interviewed the Administrator who denied telling R1 that they were not allowed to ask for assistance from the caregiver at night. The Administrator provided LPA with proof of a bedside commode that was delivered to the facility on 06/04/2025 for R1’s use. The Administrator stated that one (1) commode was placed in R1’s room near their bedside and one (1) was placed in the facility bathroom but R1 refused to utilize either commode. Interviews with the Administrator and S1 revealed that they are aware that staff are required to assist residents at night. The interview with Resident #3 (R3) revealed that in the past they have asked S1 for assistance with changing at night and S1 has assisted them. No current residents interviewed had concerns about being left in soiled garments for extended periods of time. Based on the information obtained during interviews and physical plant tour although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Staff left resident in soiled diapers/clothes for an extended period of time” Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of “Staff put residents to bed early.” alleges that facility staff require residents to remain in bed after approximately 7:00 PM each day. Interviews with the Administrator, S1, R2, R3, and R4 revealed that there is no specific time residents are required to be in bed, but residents are expected to keep noise at a minimum in the evening to be respectful to the other residents of the facility. The Administrator informed LPA that R1 would utilize their personal laptop and speaker to conduct personal conversations until approximately 11:00 PM which caused disturbances to the other residents. LPA reviewed the facility house rules and observed the following “TV, radio, and all noise must be turned down after 10:00 PM.” LPA did not observe house rules relating to a curfew or enforced bedtime for residents. Based on the information obtained during interviews and physical plant tour although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Staff put residents to bed early.” Therefore, the allegation is deemed Unsubstantiated at this time.