Inspector’s narrative
What the inspector wrote
It was alleged that R1 had a fall and was discovered soaked in urine. LPA interviewed AD who stated that R1 is currently at the hospital. Per the facility’s wellness director, R1 was hospitalized on December 31, 2025, due to a cognitive change of condition and will be reassessed prior to their return. LPA inspected the facility, conducted health and safety checks, and observed no health and safety issues. LPA reviewed the facility’s care notes dated December 29, 2025, which indicate that on December 29, 2025, R1 had an unwitnessed fall, stated they had rolled out of bed, complained of pain on their tail bone, was sent to the hospital, and returned after a few hours. LPA interviewed the staff that discovered R1 during this incident who confirmed that R1 wears diapers and was found soaked in urine, but stated that R1 was cleaned and changed immediately and was unable to state how long R1 had been soiled. Per the facility’s call button logs, R1 did not call for assistance with incontinence care prior to being found soaked in urine. LPA interviewed the facility’s wellness director who stated that R1 does use diapers, but is independent with diaper changes and does not receive incontinence care from the facility, although facility staff will provide incontinence care if they observe that R1 needs it. LPA reviewed R1’s Needs and Services Plan dated November 9, 2024, which indicates R1 is independent with toileting. The facility’s wellness director stated that R1 will be reassessed to determine if they need to receive incontinence care in the future. While R1 was observed to be soiled, R1 was independent with toileting needs at the time and staff provided incontinence care when they noticed R1 needed it.
Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
Regarding the allegation that staff did not assist a resident in care: it was alleged that R1 had a fall, was left on the floor for a long period of time, the staff who discovered R1 did not help R1 get up, and other staff had to come to help R1 get up. LPA interviewed AD who stated that R1 is currently at the hospital. Per the facility’s wellness director, R1 was hospitalized on December 31, 2025, due to a cognitive change of condition and will be reassessed prior to their return. LPA inspected the facility, conducted health and safety checks, and observed no health and safety issues. LPA reviewed the facility’s care notes dated December 29, 2025, which indicate that on December 29, 2025, R1 had an unwitnessed fall, stated they had rolled out of bed, complained of pain on their tail bone, was sent to the hospital, and returned after a few hours. LPA interviewed the staff that discovered R1 during this incident who stated that they found R1 on the floor, R1 was complaining of pain on their hip, the protocol for this situation is for paramedics, not staff, to assist the resident up, and that they followed the protocol by calling paramedics and having other staff come and make R1 comfortable until paramedics arrived. This staff was unable to state how long R1 had been on the floor, but reported hearing R1 yelling for help while they were attending to a nearby resident. Per the facility’s call button logs, R1 did not call for assistance in relation to their fall. LPA reviewed R1’s Needs and Services Plan dated November 9, 2024, which indicates R1 is independent with walking and transfers. Per the facility’s wellness director, R1 is independent with activities of daily living, but will be reassessed to determine if they need to receive additional care in the future. Although R1 had a fall, no information was obtained that R1 sustained an injury, as they returned from the hospital after a few hours, and facility staff followed proper protocol by making R1 comfortable but having paramedics assess R1 prior to attempting to help R1 up.
Regarding the allegation that staff did not respond to residents call button: it was alleged that multiple staff are not responding to residents’ calls for assistance. LPA inspected the facility, conducted health and safety checks, and observed no health and safety issues. LPA interviewed AD, the facility’s wellness director, and two staff who denied the allegation. LPA reviewed the facility’s call button logs which show that staff are responding to residents’ calls for assistance. LPA interviewed 10 residents and did not obtain information corroborating the allegation.
The Department has investigated the above allegations and found them to be Unfounded, meaning the allegations were false, could not have happened, or are without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
