Complaint·August 9, 2024

***report continues from LIC9099*** At the facility LPA reviewed R1’s file and interviewed S1 and S2 and toured the memory care unit. R1 was admitted to the facility on 3/23/2024, admitted to hospice on 4/08/24 and passed away on 7/23/24. S1 stated that she never heard any complaints about R1’s care from R1’s Responsible Party. S1 did state that she heard that the RP was rude to the facility staff and was very disruptive during her visits to the Memory Care Unit where R1 resided. S2 stated that R1 was monitored closely by the Memory Care Unit staff and was never left unsupervised for extended periods of time. R1 did develop several wounds while in care due to R1 being bed bound while also being very restless. The wounds were treated as prescribed and never developed past Stage 1. S2 further stated that R1’s was given bed bath’s 3 times weekly. LPA confirmed this by reading the care notes in R1's chart. Allegation: Staff left resident without care and supervision for an extended period of time. R1 was visited by W1 on a daily basis. W1 always observed that staff were attending to R1. R1 also had visits from Hospice 3 - 4 times a week and a Nurse twice weekly. Review of chart notes do not document any concerns about R1’s care and supervision. This allegation is unsubstantiated. Allegation: Resident in care developed a wound due to lack of staff supervision. R1 did develop wounds while in care. S2 stated that it is not uncommon for bed bound residents on hospice to develop these types of wounds. S2 further stated that R1’s wounds were not due to a lack of staff supervision but due to R1’s deteriorating condition. This allegation is unsubstantiated. Allegation: Staff did not ensure that resident's hygiene needs were met while in care. Review of R1’s chart and interview with S2 revealed that R1 was receiving assistance with his activities of daily living on a daily basis and receiving bed baths 3 times weekly. This allegation is unsubstantiated. ***report continues on LIC9099C*** ***report continues from LIC9099C*** Allegation: Staff did not ensure that resident was fed while in care. Over the course of R1’s time at the facility (4 months) R1 went from being on a regular diet and able to feed himself independently to being placed on a puree diet where he needed staff assistance. S2 stated that R1 simply lost to desire to eat and that R1 always had a staff person assigned to him to assist during meals. This allegation is unsubstantiated. Allegation: Staff did not follow personal hygiene and sanitation practices. LPA toured Memory Care Unit and observed all staff wearing gloves and masks. Hand washing signs are posted by each sink. S2 stated that all staff receive training on personal hygiene and sanitation practices. LPA asked 2 memory care staff when they are required to wash their hands, both replied "all the time." This allegation is unsubstantiated. This agency has investigated the complaint alleging staff left resident without care and supervision for an extended period of time, resident in care developed a wound due to lack of staff supervision, staff did not ensure that resident's hygiene needs were met while in care, staff did not ensure that resident was fed while in care and staff did not follow personal hygiene and sanitation practices. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.