complaint·November 19, 2025

The investigation revealed the following: Allegation: “Staff refused to change resident's soiled diaper”, it is being alleged that facility staff refused to change R1’s soiled diaper. Interview conducted with R1 revealed the following: R1 denied the allegation. Additionally, R1 explained that in the morning of 11/10/2025, facility staff came to their room changed them and got them ready for their medical appointment. Furthermore, R1 left the facility and outside the facility premises had a bowel movement, once R1 arrived at their medical appointment R1 had a soiled diaper. R1 indicates that facility staff do assist with incontinent care needs and have never refused to change their soiled diaper. Interview conducted with S1 revealed the following: S1 indicated that facility staff did not transport R1 to their medical appointment. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Executive Director Jennifer Rivas.