Complaint Investigation Report

Regarding the allegation "Facility staff did not provide sufficient incontinence care” it was alleged staff did not assist Resident #1 (R1) with incontinence care on 11/29/25 until around 4:00 p.m. R1 was found in a soiled diaper and wet clothing at that time by Witness #1 (W1). W1 stated Staff #1 (S1) and Staff #2 (S2) then came to assist R1. Interview with R1 at 4:00 p.m. on 12/03/25 revealed they were not assisted by staff and felt unwell after recovering from a Urinary Tract infection (UTI). Telephonic interview with Staff #1 (S1) at 10:45 a.m. today confirmed they began their shift around 2:30 p.m. and found R1 in a soiled diaper and clothing later that afternoon. S2 was unavailable for interview. Interview with Staff #3 (S3) at 9:30 a.m. on 12/02/25 revealed they had found R1 in a soiled diaper and wet clothing another time. Record review of R1’s medical assessment indicated they were incontinent and relied upon staff for toileting assistance. Review of R1’s care plan indicated staff were responsible for assisting R1 with all activities of daily living. Based on interviews and record review, there is sufficient evidence to confirm the allegation. Therefore, the allegation is deemed SUBSTANTIATED at this time.

Regarding the allegation "Facility staff did not provide proper diabetes assistance" it was alleged R1’s blood sugar level was too high on the evening of 11/29/25 due to improper staff assistance. Record review of R1’s medication list and Medication Administration Record (MAR) revealed they were prescribed two (02) pills to manage their diabetes, Metformin and Glipizide. Telephonic interview with R1’s physician revealed R1's Glipizide was discontinued, however the facility should have assisted with Metformin. The MAR indicated Staff #4 (S4) did not assist R1 with taking Metformin on the morning of 11/29/25. S4 wrote in the MAR notes that R1 was “physically unable to take” the medication. S4 was unavailable for an interview to explain the notes. Interview with Staff #5 (S5) at 4:00 p.m. on 06/16/26 revealed R1 monitored their blood sugar on their own and depended on staff for medication assistance. S5 could not explain why R1 was not assisted with Metformin on 11/29/25. Based on interviews and record review, the facility did not provide proper diabetes assistance. Therefore, the allegation is deemed SUBSTANTIATED at this time.

No immediate health or safety concerns observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.