Complaint Investigation Report

The investigation revealed the following: Allegation #1- Staff do not meet incontinent care needs of residents.

The details of the complaint alleged that the facility staff do not meet the incontinent needs of its residents. It was reported that staff often double brief a resident and have them go many hours without being changed. On 4/7/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not meet incontinent care needs of residents. All staff stated that they do meet the incontinent care needs of their residents. Staff stated that the residents are checked on every two hours throughout the day to see if they need to be changed. Staff also stated that some residents may need to be checked on more often, it all depends on their care plan and the needs of a particular resident. Staff further stated that it is not a practice to double brief a resident in the facility.

The department interviewed residents (R1-R6) about the allegation and 6 of 6 residents that were interviewed stated that their incontinent needs are being met and that staff does assist them promptly as needed throughout the day.

The department reviewed the Physician’s Report (Dated: 08/24/2021, 07/18/2023, 12/29/2022, 04/08/2025, 04/19/2023, 06/28/2023) and Resident Service Plan (Dated: 08/24/2021, 07/25/2023, 01/12/2023, 06/11/2025, 09/12/2023, 07/04/2023) and observed that there is a plan in place to assist those residents who are incontinent.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not meet incontinent care needs of residents. 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 #2- Staff do not ensure hazardous items are inaccessible to residents.

The details of the complaint alleged that the facility staff does not ensure hazardous items are inaccessible to residents. It was reported that the facility staff leave items that are hazardous to residents like shampoos, lotions, and ointments in reach of the residents causing a safety risk. On 04/7/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not ensure hazardous items are inaccessible to residents. All staff stated that the facility ensures that any items that are hazardous or unsafe for residents who have behavior issues are always in a locked cabinet. Staff further states that they have not observed any hazardous or unsafe items that were immediately accessible to residents nor has anyone complained about it.