Complaint Investigation Report

Allegations: “Resident was left in a soiled diaper” and “Resident is unable to communicate with staff due to language barrier.”

It was reported that on 09/17/2025, emergency services responded to a 911 call from the facility with complaints of chest pain from Resident #1 (R1). R1 was observed to be in a soiled diaper that leaked through their shirt and mattress. It was also alleged that residents are unable to communicate with facility staff and staff were unable to provide emergency services information for the residents in care due to a language barrier. Interview with three (3) out of four (4) residents revealed they have not experienced being left in a soiled diaper for long periods of time. R1 reported that there were two (2) previous occasions that they believed they were not changed but was not certain about their answer. Resident #2 (R2) reported that they were unsure if they utilized an adult diaper. Resident #3 (R3) and Resident #4 (R4) reported having no issues with their diaper changes and that staff are attentive to their incontinence needs. Record review showed that two (2) out of five (5) residents require some assistance with toileting/incontinence needs while three (3) residents required full assistance. Staff #1 (S1) and Staff #2 (S2) reported that they conduct physical checks on residents often with diaper checks every two (2) to three (3) hours, and more if needed. S1 stated diapers are changed often, and in addition to routine checks, if staff smell a foul odor they will change the resident immediately. S2 stated some residents can utilize the bathroom or communicate to the staff if they are soiled. S2 also educated the more independent residents on how to change their own diapers, however, staff will continue to assist with changes as needed.

Residents reported that they had no issues with communication with staff. R3 stated S1 can sometimes have difficulty with communicating due to limited English. R3 and R4 stated that they communicate with S1 by repeating themselves and using hand gestures or signals for better understanding, to which S1 then successfully understands and can fulfill their requests. R1 described the staff as “ok” and R1 had no problems with staff communication. Residents had no overall complaints about the staff and their abilities for meeting resident needs. Interview with S1 was accomplished through the utilization of a translator app, however S1 was able to respond to the LPA’s questions with basic English.