Complaint·December 8, 2025

On July 15, 2025, LPA Monter interviewed residents R1-R3. All residents interviewed were unable to respond to questions about complaint allegations due to their neurocognitive disorders. On July 15 & 24 and August 13, 2025, LPA Monter interviewed Staff S1 and S2. Both admitted they were using multiple diapers on R1, due to R1’s urination, which soils his/her bed and the resident him/herself. S1 stated if residents R1 or R2 get wet at night, they will use 3-4 diapers. S2 stated only R1 has multiple diapers at night. Both staff interviewed acknowledged there wasn’t a difference between R1 soiling him/herself at night or during waking hours. On July 15 & 24 and August 13, 2025 LPA interviewed ADM. ADM admitted staff place double diapers on R1 at night. ADM stated Only R1 has 2 diapers, because he/she has heavy urination. LPA asked ADM if there is a discrepancy with R1 when he/she soils him/herself in the morning, evening or night. ADM acknowledged that there wasn’t a difference. ADM stated R1 has two diapers at night because at night is easier to take it off and change him/her when he/she has 2 diapers. ADM stated she did instruct her staff to put 2 diapers on R1 at night. Based on a review of R1's Appraisal / Needs and Services Plan (ANS), dated May 28, 2025, R1 has episodes of yelling, screaming and hitting staff. Furthermore, the ANS states R1 needs 2 people during care. The ANS does not outline a specific bowel and bladder management plan for resident R1. The Department has completed the investigation of the above allegation. Based on interviews conducted and records review, the department has found that the above allegation were UNFOUNDED, meaning that the allegation was false, could not have happened and/or are without a reasonable basis.