complaint·November 13, 2025

Per physican report R1 did not have issues with bowel or bladder impairment and was able to care for own toileting needs. Based on care plan from May 2023 resident was not incontinent in either bowel or bladder. R1 was able to ambulate with the use of a walker and was able to communicate their needs. Based on internal chart notes, after R1's hospital stay on 08/14/2023 staff was providing assistance with incontinent care. It was alleged the facility left resident unattended in soaking wet and dirty diapers for extended periods resulting in multiple UTIs, based on interviews with 4 out of 4 staff stated they do not leave residents in dirty diapers for extended periods. Per interviews staff stated all residents are checked at minimum every two hours unless resident's care plan requires more frequent checks. Interviews with Current Executive Director (ED) Christian Otbo stated that if residents are refusing services such as incontinent care or showers staff will document and reach out to family for assistance. Based on interviews conducted 4 out of 4 staff stated although the residents can be difficult and not want to be changed they will utilize another caregiver in hopes that will ease the resident and allow for the service to be provided. Per interview with Med-tech stated if residents refuse medications it will be documented and the physician will be notified. Med-tech staff stated once they provide medication to the resident they are trained to remain with residents until medications are taken and will check for cheek pocketing of medications. Per review of R1's medication administration records medications were refused by R1 on multiple occasions in August 2023 and were documented. Per ED stated they were no complaints about facility management oversight in 2023 or currently. Per interviews with 3 out of 4 staff stated they do not have concerns about management oversight, 1 staff member was not asked about management oversight. Per interview with ED stated the facility has used staffing agency to fill shifts they could not cover. Interviews with 4 out of 4 staff stated they did not feel they were understaffed. Interviews with 4 out of 4 residents stated their needs are met. Therefore based on the preponderance of evidence through records reviewed and interviews the allegations Staff left resident unattended in soaking wet and dirty diapers for extended periods resulting in multiple UTIs ,Staff mismanaged resident's medication, Facility lacks management oversight ,Insufficient staffing to meet residents’ needs are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided.