Complaint Investigation Report

The investigation revealed the following:

Allegation: Resident sustained unexplained injuries while in care. It is being alleged that a resident sustained some skin tears, possibly done when staff tried to reposition the resident. On 04/26/25, between 10:25 AM and 12:00 PM the department interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed were not aware of the allegation. 5 out of 5 staff interviewed stated that all clients are treated with care, patience, dignity and respect.

On 04/26/25, between 01:10 PM and 02:40 PM, the department interviewed R1-R8. Based on interviews conducted, 8 out of 8 residents interviewed did not know of a resident sustaining unxexplained injuries while in care. 8 out of 8 residents interviewed stated that facility staff is providing them with the necessary care and supervision. 8 out of 8 residents interviewed stated that they are satisfied with the services being provided to them.

Based on interviews, a review of records, and observation, the above allegation is found to be Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Allegation: Residents are left in soiled diapers for extended period of time. It is being alleged that a resident was found drenched in urine and that they had not been checked on since the night before. On 04/26/25, between 10:25 AM and 12:00 PM, the department interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed stated did not know of a resident being left in soiled diapers for an extended period of time. 4 out of 5 staff interviewed stated residents are changed every 4 hours and as needed, and 1 out of 5 staff interviewed stated they did not know how often residents were changed.

On 04/26/25, between 01:10 PM and 02:40 PM, the department interviewed R1-R8. Based on interviews conducted, 7 out of 8 residents interviewed stated they did not know of a resident being left in a soiled diaper for an extended period of time, and 1 out of 8 residents stated they have been left in a soiled diaper for an extended period of time.