Complaint Investigation Report

During the present visit, LPA requested the facility's resident census and toured the physical plant again. Additional resident records were requested and reviewed.

Regarding the allegation that Staff does not ensure resident's diapering needs are being met , the following has been concluded: Based on assistance logs and incontinence logs provided, regular checks and diaper changes were being performed and documented during each shift in order to manage R1's assessed incontinence. Resident interviews failed to evidence any failure to address incontinence issues in a timely manner.

Regarding the allegation that Staff does not ensure resident is provided clean clothing , the following has been concluded: During the initial investigation visit, LPA observed R1 relaxing in bed dressed in clothing that appeared to be free of visible stains and odors. Logs provided by facility staff appear to evidence due diligence conducted in order to ensure R1 was not provided with soiled clothing.

Regarding the allegation that Staff does not ensure the safety of residents by monitoring entry and egress , the following has been conducted: Per the current plan of operation in place, the facility did not staff a front desk full time. However, facility policies required that visitors systematically sign-in as well as residents sign out prior to exiting the premises. Alert system preventing exits that would not be monitored are stated to be in place. Entry logs and sign-out logs were provided and appear to demonstrate most visitors do indeed abide by the facility's policy.

As a result, all three allegations listed above are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.