Complaint Investigation Report

Based on record review, R1 lived in the facility for only 5 days from 03/05/2025 – 03/09/2025.

3 staff members were interviewed. Based on staff interview, resident (R1) was very demanding and asked to be changed at every hour, even when he/she was dry. It was stated that the facility staff changed R1’s diapers every couple hours, or as needed if resident was soiled. The facility staff logged each time they change, turn and repositioned R1.

1 witness (W1) was interviewed. Based on witness interview, it was stated that R1 asked to be changed and wiped at every hour during the night. W1 states that he/she tried to accommodate to R1's needs and assisted R1 at every request. W1 states there to be one time where W1 was on break eating lunch at the facility's kitchen table where R1 asked to be changed. W1 states that he/she informed R1 that he/she will be back and came back in 15 minutes. W1 denied coming back after an hour.

3 out of 3 staff denied leaving a resident and R1 soiled for a long period of time.

1 resident was interviewed. 4 out of 5 resident interviews were attempted. Based on resident interview, the resident denied being left in soiled diapers for a long time. Resident states that the staff assist him/her whenever he/she needs assistance. Resident stated the staff responds to him/her right away and never had to wait more than 10 minutes for help.

Based on record review of the facility’s activities of daily living (ADL) log, it shows that R1 diaper was changed every 2-3 hours from 03/05/2025 – 03/09/2025.

It was alleged that the facility staff did not feed resident as the resident stated that he/she had not eaten.