Complaint Investigation Report

On February 28, 2025, Licensing Program Analyst Monter interviewed residents R2-R7. R2 and R6 stated his/her bathroom needs are being meet at night. R3-R5 stated they doesn’t need assistance to use the restroom. Residents R2-R6 stated they have a call pendant they can press at night, and a care giver will assist them at night. Resident R7 stated he/she declined to be interviewed.

LPA interviewed staff S1 and S2. S1 stated all the residents have a pendant. S1 and S2 stated if the residents need help, they press the pendant, and staff will go help them. S1 and S2 stated assistance is always provided when residents press the pendant.

LPA interviewed Licensee Ladwig. LN stated R1 has the condition of going to the bathroom at night. LN stated R1 had an issue of having the sensation of needing to go to the bathroom. LN stated the staff was able to meet R1 needs incontinence needs at night.

On April 9 and 21, 2025, LPA Monter interviewed staff S3-S5. Staff S3 stated he/she works the night shift. S4 stated he/she will cover the night shift for S3 when he/she calls in sick. S3 and S4 stated residents are checked/ changed every 2 hours at night. S3 and S4 stated staff respond to pendants, when pressed during the day and night. S3 and S4 stated they didn’t work with R1.

Staff S5 stated he/she did work with R1 during the night shift. S5 stated resident R1 will get up multiple times at night, at least 4 times a night. S5 stated R1 will go to the bathroom by him/herself. S5 stated resident R1 has unsteady balance and for R1’s safety staff needs to be there to assist R1 in walking. S5 stated R1 will get out of his/her bed and use his/her walker to go to the bathroom, which is only 5 feet away from the bathroom.

S5 stated he/she will hear a noise and will hear R1’s walker and S5 will go to assist R1.

S5 stated R1 will sometimes use the pendant, call button to get assistance, but R1 most of the time would rather go by him/herself to the bathroom.