Complaint Investigation Report

During today's visit, LPA obtained the following documents: staff and resident rosters. LPA interviewed the Care Coordinator and Resident #15 (R15).

The investigation revealed the following: in regard to the allegation, “Staff do not ensure that resident's incontinence needs are met.” It is alleged that on 12/12/2025, R1 is supposed to have her incontinence supplies changed every two hours but R1 waited four hours to be changed. LPA interviewed one (1) out of 15 residents that corroborated with the allegation stating waiting for four hours for incontinence supplies to be changed when staff are supposed to change incontinence supplies for the resident every two hours. One (1) out of 15 residents corroborated with the allegation stated wait one hour and a half from the scheduled time to be changed. LPA also observed Resident #14 R14’s) room had a strong urine odor. Two (2) out of 15 residents interviewed could not confirm nor deny the allegation since they stated they do not require any incontinence supplies change from the staff. 11 out of 15 residents denied the allegation by stating that the staff meets their incontinence needs and they don’t have any problems. LPA interviewed the Executive Director, Care Coordinator and one (1) out of seven (7) staff corroborated with the allegation stated that there was a delay in providing incontinence change for residents on 12/12/2025 and the incontinence change service for R1 was provided at 9:15am which is two hours when it should have been done at the scheduled time of 7am. LPA interviewed Care Coordinator which stated that 40 to 48 residents out of the facility census of 147 residents required incontinence change service in the AM shift on 12/12/2025. Per Care Coordinator interview, there are normally five (5) caregivers on duty in the Friday AM shifts on which each caregivers are assigned 10 to 12 residents that need incontinence change service. LPA observed the staff schedule for 12/12/2025 and confirmed with the Executive Director and the Care Coordinator that there were two (2) caregivers calling off and one (1) caregiver off on vacation. Per Executive Director and Care Coordinator interview, there were only two (2) caregivers in the AM shift to provide incontinence change service for 40 to 48 residents which caused a delay in providing incontinence change service for residents on 12/12/2025. LPA interviewed the three (3) out of seven (7) staff that denied the allegation by stating that the care staff change the residents in a timely manner. LPA interviewed three (3) out of seven (7) staff that could not confirm nor deny the allegation since they are not involved in providing this service. Therefore, there was sufficient evidence to corroborate with the allegation.

Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.