Complaint Investigation Report

Allegation #1: Staff leave clients in soiled diapers for an extended period of time .

The complaint alleged that staff do not change clients’ diapers during their shift and leave diaper changes for the morning staff. On 02/18/2026, LPA Richard interviewed the Administrator (A1), who denied the allegation. A1 stated that staff receive sufficient training, structure, guidance, and support to assist clients during the night shift, including assistance with personal care needs.

On 02/18/2026, LPA interviewed four staff members (S1–S4). All denied the allegation and stated that the facility has only one client (C4) who wears diapers and requires assistance with changing every two hours or as needed. Staff reported that diaper changes are completed according to the client’s needs and care plan. Additionally, LPA interviewed four clients (C1–C4), all of whom denied the allegation and stated that staff provide assistance when needed. C4 specifically stated that staff change their diapers regularly throughout the day.

On 02/18/2026, LPA conducted a record review of staff training documentation, as well as the AM and PM shift task lists. Documentation indicated that staff are responsible for complete regular diaper changes as required. LPA also observed the facility to be clean and orderly. Clients were observed playing games and interacting appropriately with staff.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated.