Complaint·March 18, 2026

LPA interviewed relevant party in which they stated they observed R1 saturated with urine several times. LPA interviewed 4 care staff who helped R1 with care, and they stated they changed R1 every 2 hours or as needed. No care staff reported issues with R1’s continence care. Due to the information gathered LPA finds allegation to be Unsubstantiated. LPA investigated allegation, “Staff did not report incidents to responsible party”. LPA reviewed hospice and facility information and interviewed relevant party and staff. LPA reviewed hospice documentation and observed there were no concerns with facilities reporting. LPA reviewed facility documentation, in which staff documented several incidents and each time it was documented that family and hospice were notified. LPA interviewed relevant party in which they stated there were several times that facility did not report to R1’s family concerning incidents and only found out through hospice. LPA interviewed 4 care staff in which they stated whenever something occurred with R1 they would report the issue to the family and hospice immediately. Care staff had no concerns with reporting incidents to families. Due to the information gathered LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted.