Complaint Investigation Report

LPA investigated the allegation that Staff do not ensure that residents' incontinence needs are met. LPA reviewed two of two resident files and both residents were non-ambulatory. Resident #5 (R5) receives hospice services and the Preplacement Appraisal states the resident needs full assistance with bathroom functions. The Medical Assessment dated April 13, 2026 report resident has bowel and bladder impairment, requires continuous bed care and is unable to care for own toileting needs. LPA attempted to interview R5 but was unable to interview.

LPA interviewed seven of nine residents. One resident confirmed the allegation that incontinence needs are not being met. Five residents interviewed denied the allegation and had not heard or witnessed residents sitting in soiled diapers. One resident could not confirm nor deny the allegation. LPA interviewed seven of seven staff members who denied the allegation.

It was alleged that Staff inappropriately speaks to residents. One of nine residents confirmed this allegation regarding an incident that occurred in the middle of the night. Six of nine residents denied having this experience with staff. Two of nine residents could not confirm, nor deny the allegations.

LPA reviewed three of three staff records who work at night and there were no documents regarding corrective action. Three of three staff members had signed personal rights and mandated reporter documents. LPA observed staff training regarding Resident Rights and are provided ongoing training. LPA interviewed seven of seven staff members. Three of the seven staff members interviewed work at night and stated there have been no complaints or issues from residents regarding their work or behavior and that they were unaware of the incident reported in the complaint. Seven of seven staff members denied the allegation.

The Department investigated the allegation that: Staff do not safeguard resident's personal belongings. Two of nine residents reported they have had issues with missing personal belongings. One of the residents stated they report missing items to staff but staff are unable to locate the items. The second resident stated they were missing an item in their apartment but that the staff was able to assist the resident in finding it.