Complaint Investigation Report

LPA interviewed five (5) facility staff members, who indicated that incontinence care checks are conducted routinely, typically in the morning and at night, and every two (2) hours for hospice residents or residents identified as requiring more frequent care. S2 stated that some residents refuse incontinence checks, which are then documented and communicated to the next shift. Staff stated that progress notes are maintained for each resident to track care needs. Regarding the reported fall, staff reported that the incident occurred in the designated outdoor smoking area. S2 also stated that Resident R1 did not require one-on-one supervision at the time of the fall and that the resident reported attempting to reposition while seated, which resulted in the incident. Facility records confirmed that the resident was transported to the hospital for evaluation following the fall.

During the facility walkthrough, LPA observed Resident R1's room being cleaned by housekeeping staff. The room appeared clean and free of odors. The housekeeper interviewed stated that rooms are cleaned weekly and expressed no concerns regarding the provision of incontinence care by care staff.

LPA also conducted interviews with five (5) residents. All five (5) residents expressed general satisfaction with the care and services provided. Residents reported that staff assist with cleaning, laundry, and personal care as needed, and that rooms are kept clean. No residents reported concerns regarding incontinence care, supervision, or personal rights violations.

Based on information obtained through interviews, record reviews, and observations, there was insufficient evidence to support the allegations that the facility failed to meet incontinence care needs, that a lack of supervision resulted in a resident injury, or that resident personal rights were violated. Although the resident did experience a fall, the evidence did not show that the facility failed to provide appropriate supervision or care as required. Therefore, the allegations are UNSUBSTANTIATED . A finding that a complaint allegation is Unsubstantiated means that although the allegations may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.