complaint·September 30, 2025

Allegation: Staff left residents in a soiled diaper for a long period of time. It was alleged that staff left a resident in soiled undergarments for an unknown, extended, period. LPA interviewed 4 staff members via telephone who all stated residents are changed as soon as possible. Staff reported there are several residents in the facility who are incontinent and require regular toileting care. Staff also reported there are a few residents who may become confused or combative when staff attempt to assist with toileting needs. Staff explained that because of this behavior, there are times when staff may need to allow a brief period when staff need to call for assistance or request a “change of face” for the resident by having a different staff member assist, however, no resident is left in soiled undergarments very long. On April 18, 2025, LPA attempted to interview three residents at the facility but was unsuccessful. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to RCC, via email. Allegation: Staff did not seek medical attention in a timely manner . It was alleged R1 sustained a fall, and the facility failed to seek medical attention for this resident in a timely matter. On March 20, 2025, the department received an incident report documenting R1’s fall that occurred on March 19, 2025. The report further documented R1’s subsequent transport to the hospital for evaluation. Additionally, on March 28, 2025, the department received a separate incident report documenting another transport for R1 to the hospital for follow-up after R1’s bruising from the fall appeared to worsen. Based on information above, it is concluded that the allegation is Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Allegation: Staff did not report an incident to licensing. It was alleged that R1 had sustained a fall that the facility failed to report to licensing. On March 20, 2025, an incident report was provided to Community Care Licensing via fax documenting a fall sustained by R1. Emergency Medical Services (EMS) was called and R1 was transported to the hospital for evaluation. Based on information above, it is concluded that the allegation is Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to Residential Care Coordinator, via email.