Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff left residents in soiled diapers for an extended period of time

The detail of the complaint alleges “the staff lets residents walk around with 'saggy' diapers in the facility instead of changing them.”

On November 25, 2025, and January 15, 2026 the Department interviewed (A1) who denied the allegation stating that residents are not left soiled for an extended period of time. A1 further stated that the protocol for changing residents’ diapers: “…is based on typical checks of 1 to 2 hours and based on the needs of the residents whether they need to be changed and whether they are checked for urine output or bowel movements.”

On November 25, 2025, between 8:00am and 4:00pm, the Department interviewed staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating they haven’t observed any residents left soiled for an extended period of time. 5 out of 5 staff stated that they are trained to care for residents who are incontinent. Additionally, 5 out of 5 staff stated that they typically change residents every 2 hours and/or sooner if necessary.

On January 15, 2026, between 10:00am and 12:30pm, the Department interviewed 5 residents (R2-R5, R7) and Witness #1(W1). The department could not interview R1 as R1 no longer lives at the facility (passed away as of 11/24/25), R6 was not available at time of visit. Of those interviewed, 4 out of 5 state that they are never left in soiled diapers for extended periods of time. 1 out of 5 was not responsive to questions due to cognitive level. 4 out of 5 state that staff change them when they need changing. W1 a private/hire caregiver for R5 states staff is attentive and that she has not witness any instances where R5 complained of being left soiled since she worked with her.