complaint·January 24, 2022

that the facility staff were in constant communication with their health providers and also sent R1 to the emergency room once pressure injuries worsened. LPA Williams reviewed documentation from the facility in which it appeared that a home health agency was caring for R1's pressure injuries. In addition, the documentation appeared to show that facility was in constant communication with R1's health care providers and sought a higher level of care for R1's pressure injuries when needed. In regards to allegation #2, LPA Williams interviewed S1, S2, and Staff # (S3) who denied that residents are left in soiled diapers for extended periods of time. S1, S2, and S3 stated that the facility staff check/change incontinent residents every two hours or as needed. LPA Williams interviewed R1, who stated that they do not recall an incidence where they were left in a soiled diaper for an extended period of time. LPA Williams also interviewed Resident #2 (R2) who denied that any incidence where they were left in a soiled diaper for an extended period of time. R2 stated that facility staff are meeting their incontinence needs appropriately. In regards to allegation #3, LPA Williams interviewed S1, S2, and S3, who all stated that resident care needs are being met appropriately. S1 stated that there is sufficient staffing to care for residents and appropriate training provided to facility staff regarding resident care. LPA Williams interviewed R1 and R2 who both stated that their care needs are being met while residing at the facility. R1 stated that they have "no complaints with the facility." R2 stated that facility staff "are doing a great job." Based on evidence obtained during the investigation, LPA Williams has determined that the above allegations are UNSUBSTANTIATED; meaning that 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. An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to the Administrator at the conclusion of the investigation.