complaint·January 22, 2026

with staff stated that R1 does not wear diapers and there is no reason why resident would be left soiled when they are independent with toileting. Interview with witness stated that they never indicated that R1 was left soiled for 6 hours or for extended period of time. It is alleged that due to lack of supervision, resident fell and was on the ground for an extended period of time, specifically when R1 was showering. Interview with staff stated that R1 is on shower schedule and outside of that they do not shower on their own. If R1 had a fall staff would have known or been present due to being on shower assistance. Record review revealed that R1 is reflected on shower schedule. Resident assessment reflects that R1 requires standby assistance with showers 2x per week. Need and services plan reflects R1 is on shower standby assistance. Interview with witness stated that they did not indicate that R1 had been on the ground for an extended period of time or for 8 hours. It is alleged that due to lack of supervision, resident was stuck between the wall and the mattress for an extended period of time resulting in hospitalization. Record review did not reflect any unusual incident with R1 recently. The last incident reported to the department was on August 16, 2024. Interview with staff stated that the last incident R1 had was for an unwitnessed fall back about 18 months ago, but nothing recent. Due to that incident R1 was reassessed and needs and services plan were updated and was also reassessed for any changes in condition. Interview with witness stated that they did not indicate R1 was stuck between the wall and the mattress for extended period of time, but R1 had gotten their arm stuck between the recliner and the wall, but it was in an instant with no injuries. There was no fall and/or the bed and it wasn’t for an extended period. Therefore, the Department has determined the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.