complaint·January 22, 2026

Record review of R1’s medical assessment and care plan at 12:00 p.m. on 10/08/25 revealed they were incontinent and needed toileting assistance at least three (03) times per day. Interview with the administrator at 10:50 a.m. on 10/08/25 revealed R1 had a brief period of accidents in bed and needed several bedsheet changes each week. The administrator ordered five (05) packs of new bedsheets for R1 specifically and consulted with R1’s physician about managing the incontinence. Interview with the Maintenance Director at 10:00 a.m. on 10/01/25 revealed extra bedsheets were stored in the maintenance room. At 10:10 a.m. on 10/01/25 LPA observed an adequate supply of fresh and washed bedsheets, towels, and comforters in the maintenance room. Interview with Staff #1 (S1) at 11:20 a.m. on 10/08/25 revealed R1 was pulling off their diapers in bed and soiling their sheets. S1 had changed R1’s bedsheets on 10/07/25 and 10/08/25. Interview with Staff #2 (S2) at 11:40 a.m. on 10/08/25 confirmed R1’s bedsheets were changed almost daily. S2 also confirmed the facility bought extra bedsheets just for R1. Interview with the Wellness Director at 12:30 p.m. on 10/08/25 revealed staff were aware of R1’s increased incontinence and ensured R1 was changed regularly and not left sitting in soiled diapers. The Wellness Director also confirmed R1’s physician adjusted their medications to reduce incontinent behaviors. Interview with Staff #3 (S3) at 12:45 p.m. on 10/08/25 confirmed R1 had increased incontinence recently, but staff never left R1 sitting in soiled diapers. Interviews with eleven (11) out of eleven (11) residents on 10/01/25 revealed they had never been left in soiled diapers. Based on observations, interviews, and record review, the facility adequately addressed R1’s incontinence needs by changing their diapers and bedsheets in a timely manner. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. No immediate health or safety needs were observed during today’s visit. Exit interview conducted. Copy of report provided.