Complaint Investigation Report

On 11/19/2025 and 4/20/2026 the Department conducted complaint investigation visits and interviewed 4 Staff (S1 to S4), 4 Residents (R1 to R4) and 1 Witness. 4 Out of 4 staff state he/she is not aware of and has not observed a resident left in a soiled brief. S2 states R1 preferred to change his/her own brief.

On 11/19/2025 and 4/20/2026 The Department interviewed 4 Residents (R1 to R4). 3 Out of 4 Residents stated he/she does not require any assistance with toileting. 3 Out of 4 Residents state he/she does not have any issues or concerns with the care he/she is receiving. R1 did not respond to questions due to cognitive impairment.

On 11/19/2025 the Department interviewed 1 Witness (W1). W1 states he/she has worked with R1 for approximately six months. W1 states he/she has not observed R1 left in a soiled brief due to staff not attending to residents’ incontinence needs.

Review of R1’s physician’s report dated 2/8/2024, R1 is noted to have bladder impairment. R1 is also unable to care for his/her own toileting needs and needs assistance with toileting.

Review of R1’s care plan dated 10/22/2025, R1 is noted to not require bathroom assistance, “can manage his/her own bathroom needs at this time.”

Review of R1's progress notes from 5/1/2025 to 11/29/2025, there are no noted incidents of R1 being left soiled by facility staff.

Resident fell while in care due to lack of staff supervision

On 11/19/2025 the Department interviewed the Reporting Party (RP). RP states a resident, referred to as R1, had four falls during between May 2025 to November 2025 due to lack of staff supervision. RP stated the facility informed him/her about these incidents of R1 falling.

On 11/19/2025 the Department interviewed 1 Witness (W1). W1 states he/she has worked with R1 for approximately six months.