Complaint Investigation Report

9099C-1.. Resident (R1) stated on December 27, 2023, that they are incontinent and wear diapers/pads. and has had issues with caregiver (S1) regarding not always receiving assistance with their bowel movements, since on/around October 2023. (R1) indicated that (S1) does not do their job because they were informed by another caregiver staff on the "pm" shift that they have to always change resident's diapers right after the shift change.

A second resident was attempted to be interviewed on December 27, 2023 but was not able to participate.

Staff (S1) stated on December 27, 2023 that they check on each resident every (2) to (2.5) hours, will receive alerts from residents needing assistance, and will chart all care provided to residents. (S1) stated that they assist with toileting/diaper changes within a reasonable time frame as long as they are not working with another resident and commented that they are responsible for (22) rooms on the first floor today.

On December 27, 2023, the Wellness Director stated (S1) has received employee write-ups and confirmed she has spoken to (S1) several times about why their "daily sheet stack" is insufficient compared to (2) other caregivers.

Documentation related to care provided to (R1) was not available for review, and LPA was not able to conduct a follow up interview as (R1) moved out prior to passing in early December 2025.

On February 11, 2026, the administrator confirmed with the LPA that (S1) is still presently employed at the facility, "has been doing good on light duty" and is not doing care currently.

Based on information gathered, the allegation was determined to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.