Complaint Investigation Report

RP stated R1 had not been changed since the day before and noted that this was not an isolated incident. RP stated they previously advised Staff #1 and #2 (S1 and S2) to ensure R1 was kept clean and dry. However, RP stated that both S1 and S2 continued to rely on outside care teams to manage R1’s toileting needs. LPA’s record review confirmed R1’s soiled clothing, bedding, and incontinence brief. Based on interviews conducted and record review, the Department’s investigation provided enough information to corroborate the allegation that staff are not meeting residents toileting. This allegation is substantiated.

It was alleged that staff leave resident in soiled clothing for an extended period of time. According to the information received, R1’s clothes were severely soiled, and R1 was found to have 2 incontinence briefs on at one time. LPA conducted an interview with a relevant party (RP), who stated that R1 had not been changed since the day before when they visited on July 10, 2025. RP stated that R1’s clothes, bedding and incontinence brief were severely soiled at the time of their visit. LPA’s record review confirmed R1’s soiled clothing, bedding, and incontinence brief. Based on interviews conducted and record review, the Department’s investigation provided enough information to corroborate the allegation that staff leave resident in soiled clothing for an extended period of time. This allegation is substantiated.

It was alleged that staff are not maintaining resident’s hygiene. LPA conducted an interview with a relevant party (RP) who stated that R1’s clothes were completely saturated with urine and feces. The feces were in the R1’s hair, face, hands and mouth. LPA’s record review confirmed R1’s soiled clothing, bedding, incontinence brief, and the feces on R1’s hand and face. Based on interview conducted and records review, the Department’s investigation provided enough information to corroborate the allegation that staff are not maintaining resident’s hygiene. This allegation is substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was not conducted as the facility has been closed since 09-11-2025. A copy of this report was sent to the ex-licensee’s last known address via USPS certified mail due to the facility closure.