Complaint·April 20, 2026

On 11/19/2025 and 4/20/2026 the Department conducted complaint investigation visits and interviewed 4 Staff (S1 to S4), 4 Residents (R1 to R4) and 1 Witness. 4 Out of 4 staff state he/she is not aware of and has not observed a resident left in a soiled brief. S2 states R1 preferred to change his/her own brief. On 11/19/2025 and 4/20/2026 The Department interviewed 4 Residents (R1 to R4). 3 Out of 4 Residents stated he/she does not require any assistance with toileting. 3 Out of 4 Residents state he/she does not have any issues or concerns with the care he/she is receiving. R1 did not respond to questions due to cognitive impairment. On 11/19/2025 the Department interviewed 1 Witness (W1). W1 states he/she has worked with R1 for approximately six months. W1 states he/she has not observed R1 left in a soiled brief due to staff not attending to residents’ incontinence needs. Review of R1’s physician’s report dated 2/8/2024, R1 is noted to have bladder impairment. R1 is also unable to care for his/her own toileting needs and needs assistance with toileting. Review of R1’s care plan dated 10/22/2025, R1 is noted to not require bathroom assistance, “can manage his/her own bathroom needs at this time.” Review of R1's progress notes from 5/1/2025 to 11/29/2025, there are no noted incidents of R1 being left soiled by facility staff. Resident fell while in care due to lack of staff supervision On 11/19/2025 the Department interviewed the Reporting Party (RP). RP states a resident, referred to as R1, had four falls during between May 2025 to November 2025 due to lack of staff supervision. RP stated the facility informed him/her about these incidents of R1 falling. On 11/19/2025 the Department interviewed 1 Witness (W1). W1 states he/she has worked with R1 for approximately six months. Page 2 of 3 W1 states R1 had four falls during these six months (May 2025 to November 2025). W1 states R1 was checked frequently by facility staff during the time the falls occurred. W1 stated R1 is ambulatory and uses a wheelchair and can self-transfer (to and from the wheelchair). W1 states he/she does not believe R1 fell due to staff neglect. Review of R1’s physician’s report dated 2/8/2024, R1 is noted to have motor impairment/paralysis, walks with a cane.’ R1 is non-ambulatory due to physical condition. Review of R1's progress notes from 5/1/2025 to 11/29/2025, R1 is being checked on by facility staff with noted incidents of R1 falling on 11/14/2025, 10/24/2025, 9/22/2025, and 5/6/2025. R1 was assessed by facility staff, and all responsible parties were notified of the falls. Review of R1’s care plan dated 10/22/2025, for ‘Escort & Mobility’ R1 is noted as “independent going to and from the dining room or community activities, resident has falls in the last twelve months, resident has fallen without apparent harm/injury, resident uses a cane as a mobility aid, resident uses a walker as a mobility aid, resident uses a manual wheelchair as a mobility aid." Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . An exit interview was conducted with ED and a copy of this report was provided. Page 3 of 3 END OF REPORT