Complaint Investigation Report

LPA investigated allegation, “Staff did not meet resident’s incontinence care needs.” Relevant party stated they observed R1 soaked with urine, and R1 smelled of urine. In addition, relevant party indicated R1 had a rash in the peri-area. R1 has since moved from the facility. LPA interviewed R1 in which they could not recall the facility or any issues that may have occurred. LPA interviewed administrator in which she stated R1 was able to provide their own incontinence care and manage their hygiene until few weeks prior to hospitalization. Administrator reports R1 was becoming weaker and having more incontinent care needs. Administrator stated R1 kept denying care to be provided and so they called emergency services due to hygiene needs and change of condition. LPA reviewed hospital documentation on 5/18/26 and no documentation was seen about a rash for R1 in the peri-area. R1 returned to the facility on 5/20 and then was sent out again to the hospital on 5/25/26. LPA interviewed caregiver in which they stated starting in May 2026 R1 was beginning to have incontinent accidents and denying care more frequently. Caregiver stated she would try to give R1 a shower or help them in the bathroom but R1 would refuse frequently. LPA interviewed responsible party in which they stated they did not know if facility staff meet R1’s incontinent care needs. Responsible party stated she did receive reports from medical employees that they had concerns about R1 receiving proper care. Due to the information gathered, LPA finds allegation to be Unsubstantiated.

LPA investigated allegation, “Facility staff are not administrating residents’ medication as prescribed”. Relevant party stated R1 was observed with loose pills in their pocket. LPA interviewed R1 in which they could not recall the facility or any issues that may have occurred. LPA interviewed administrator in which she stated that she gives residents their medications each day. Administrator stated she stays with the residents while hey take their prescribed medications. Administrator stated the day R1 was sent out to the hospital, she gave R1 their medications in a small cup, but they refused. EMT’s arrived shortly after, and administrator believes she took the cup of pills back and disposed of the pills. Administrator stated she could not recall the details. LPA interviewed R1’s responsible party and they stated they were unaware of any issues with the medications. Due to the information gathered, LPA finds allegation to be Unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted and copy of report provided.