Complaint Investigation Report

It was alleged that R1 had a fall and was discovered soaked in urine. LPA interviewed AD who stated that R1 is currently at the hospital. Per the facility’s wellness director, R1 was hospitalized on December 31, 2025, due to a cognitive change of condition and will be reassessed prior to their return. LPA inspected the facility, conducted health and safety checks, and observed no health and safety issues. LPA reviewed the facility’s care notes dated December 29, 2025, which indicate that on December 29, 2025, R1 had an unwitnessed fall, stated they had rolled out of bed, complained of pain on their tail bone, was sent to the hospital, and returned after a few hours. LPA interviewed the staff that discovered R1 during this incident who confirmed that R1 wears diapers and was found soaked in urine, but stated that R1 was cleaned and changed immediately and was unable to state how long R1 had been soiled. Per the facility’s call button logs, R1 did not call for assistance with incontinence care prior to being found soaked in urine. LPA interviewed the facility’s wellness director who stated that R1 does use diapers, but is independent with diaper changes and does not receive incontinence care from the facility, although facility staff will provide incontinence care if they observe that R1 needs it. LPA reviewed R1’s Needs and Services Plan dated November 9, 2024, which indicates R1 is independent with toileting. The facility’s wellness director stated that R1 will be reassessed to determine if they need to receive incontinence care in the future. While R1 was observed to be soiled, R1 was independent with toileting needs at the time and staff provided incontinence care when they noticed R1 needed it.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.