It is alleged that the facility does not change R1’s diapers frequently enough, which is causing R1 to get urinary tract infections. During staff interviews, staff consistently stated that they assist R1 with ADLs, including grooming, showers, and incontinence care, and that residents requiring increased incontinence care are checked regularly. Staff stated that care provided is documented, including toileting and brief changes, and that staff respond to R1’s requests for assistance as promptly as possible. Staff stated that care plans and hospice plans are available and followed, and that care is individualized based on R1’s preferences and needs. Staff denied concerns of neglect and stated that R1 has not complained about incontinent care. During the resident interview, R1 stated that the facility provides her with everything she needs and that staff treat her well. R1 expressed satisfaction with her living environment and stated that her overall health is good. R1 stated she does not like hospice services and would prefer to return to her prior routine. R1 acknowledged the history of UTIs and reported she is currently taking antibiotics. During resident interviews, residents R2–R8 stated they are satisfied with the care being provided and reported no concerns regarding incontinence care.

During W1 interview, W1 stated that R1 has resided at the facility for over eight years and expressed no concerns regarding the services provided. W1 reported regular communication with the hospice nurse and stated that a new incontinence care plan was developed to help reduce recurrent UTIs, noting that UTIs can be common with aging. W1 stated they will continue to communicate with hospice and facility staff and reported no additional concerns. During W2 interview, W2 stated their duties include assessing the resident, conducting regular check-ins, and coordinating care to support the resident’s comfort and well-being. W1 stated that R1 prefers care to be provided in a specific manner and that a care plan was developed between W2, R1 and W1. W2 stated that R1 has a history of recurring UTIs and that R1 reports feeling hot and experiencing burning sensations in the mornings. W2 stated that reminder signages are posted in R1’s room for caregivers to see and that care is adjusted to meet R1’s preferences. W2 described R1 as articulate, active in facility activities, and having vision impairment that causes occasional frustration. W2 stated their role is oversight and care coordination, with caregivers providing direct incontinence care per the care plan. W2 stated that they do not believe the facility neglects residents and would feel comfortable having their own family reside at the facility.

Based on the investigation conducted, including interviews with staff, witnesses and residents and review of relevant records, there was insufficient evidence to support the reported allegation. 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, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.