Complaint Investigation Report

9099C-1.The Physician's Report (LIC602-dated March 16, 2026) notes R1 has a primary diagnosis of Periprostatic Fracture Around Internal Prosthetic Left Hip joint, Acute Cystitis without hematuria, skin breakdown, Hypothyroidism, Osteoarthritis and does not have any c ognitive issues or exhibit behavioral expressions. Also noted is R1 has hearing/vision loss,is incontinent with bowel/bladder, has a Foley Catheter and requires assistance with repositioning/transferring, bathing, dressing/grooming, toileting, medications, is independent with feeding and can communicate and follow directions. It's also noted R1 has a history of skin breakdown.

Allegation: Staff are forcing resident to wear diapers. The allegation states the facility would not allow (R1) out of bed after 6pm to use their commode, forced (R1) to wear diapers until the morning, and (R1) would hold their urine all night.

R1 stated to LPA on 4/29/2026, confirmed they wore diapers at night and staff "didn’t change me at night." R1 added that facility staff "did not want me to use the commode at night and took it out of my room- and took my walker out too and said not to use it." R1 added, "I was stuck in bed until the next morning- It was a nice place, but no one was on duty at night".

One of R1's family members stated that R1 "had to wait until 8:00 am for help with going to the bathroom and had to hold it in", adding "R1 had a constant Urinary Tract Infection with a catheter and the nurse is aware. A second family member stated, R1 was forced to wear diapers at night and stated, "the frustrating part was the Admission Agreement stated staff would provide bathing, toileting" and other care, but it "doesn't give specific times for toileting".

The family member explained that R1 moved in with a catheter but their condition soon improved and they were moving around and ready to get the catheter removed. Also Home Health needed to monitor how R1 did without the catheter, as the catheter was causing R1 to get a Urinary Tract Infection (UTI). Staff (S2) caregiver, became upset that R1 was "calling too often" during the night for assistance with going to the bathroom once the catheter was removed and stated that both S1 and S2 told her and R1 that there is "no nighttime assistance available", and advised R1 not to push the button. This family member stated she explained to staff that R1 didn't feel comfortable going in the brief and "couldn't go in the brief".

A Home Health nurse stated she would usually visit R1 between 10 am and 3 pm and stated, it's normal for her clients to wear a brief, due to some kind of incontinence; however, the facility staff were "forcing the issue with the catheter". The nurse stated that R1 had a brief on which made them hold the urine in, contributing to a possible UTI, which was the reason the catheter was discontinued, explaining, "Yes, it was removed because R1 wanted it out- the catheter was in because of urinary retention. *cont on 9099C-2.