Complaint Investigation Report

R1 was admitted to the facility on 03/03/2025.

3 residents were interviewed. Based on interview, 1 out of 3 resident stated to have helped R1 clean his/her bed with a witness (W1) because R1 and R1’s bed was soiled. This resident stated to have voluntarily cleaned R1’s bed because the staff was taking too long to come to the room. This resident denied staff checking on the residents regularly and in the morning. 2 out of 3 residents interviewed stated that the staff check in on the residents daily in the morning and throughout the day, and denied observing other residents left in soiled adult briefs.

Based on interview with witness (W1), W1 observed R1 laying in bed soaked full of urine about 3 times since he/she has visited the facility. W1 was unable to recall the dates of observation. W1 stated that he/she visits the facility daily at 10:00am and around 2:00pm. It was stated that he/she has observed R1 left laying in his/her urine around 10:00am and when he/she returned to the facility at 2:00pm.

W1 states that when he/she observed R1 laying in bed soaked in urine, W1 did not tell the staff. W1 states that there was always staff in the hallways and assumed they’d check in on R1. W1 denied observing staff help R1.

The review of R1’s pre-placement appraisal notes that R1 is incontinent and did not need help with toileting but needs help with bathing and personal hygiene.

6 staff members were interviewed. Based on staff interview, it was stated that R1 came from an independent living home. The facility was informed that R1 was able to change his/her own adult briefs. It was stated that when R1 first moved in, R1 refused staff assistance to change his/her adult brief and any assistance in the bathroom. Staff stated that in beginning R1 needed to be constantly reminded to use the bathroom and change his/her adult briefs. Staff members stated that they ensure R1 is checked and asked every 2 hours to go to the bathroom and to change his/her adult brief.