Complaint Investigation Report

The investigation into the allegation, Staff are not properly reporting incidents to authorized representatives, revealed the following. It was reported that R1 sustained falls on June 9, 2025 and July 2, 2025 and R1's authorized representative/emergency contact was not notified. A review of records shows R1 sustained falls on June 21, 2025, and July 7, 2025. The Administrator reported there is no record of any falls for R1 on June 9 or July 2, 2025. R1 could not recall how many times or the dates of when they have suffered a fall. The Wellness Director reported that they have no record of falls for R1 on June 9 or July 2, 2025. 5 out of 5 staff members reported they are unaware of any falls for R1 on June 9 or July 2, 2025. R1's authorized representative/emergency contact reported that they were notified about the falls on June 21 and July 7, 2025. R1's authorized representative/emergency contact could provide any details about the falls reported to have taken place on June 9 or July 2, 2025. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated , meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff are leaving resident in soiled clothing for an extended period of time, revealed the following. It was reported that R1 was not properly assisted with incontinence issues and would be left in their soiled clothes for an hour before they were assisted and changed and this caused R1 to be hospitalized. No specific details were provided as to when or how many times this occurred. R1's physician reported that R1's hospitalization and diagnosis of Sepsis secondary to UTI could not be attributed to poor hygiene and was caused by their overall poor health. The Administrator and Wellness Director reported they were unaware of any issues assisting R1 with incontinence issues and have heard no reports of residents being left in soiled clothing. 5 out of 5 staff members reported that R1 was not neglected in any way, was never left in soiled clothing and they constantly checked on R1. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated , meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of the report provided.