complaint·July 7, 2025

***CONTINUE FROM 9099*** W1 stated R1 appeared un-showered and disheveled on several occasions.LPA’s review of the shower schedule and progress notes showed that showers were offered regularly, consistent with the care plan. Shower refusals were documented in instances, including one entry where staff noted the resident declined assistance due to discomfort. The progress notes reflect hygiene tasks were being logged routinely. S1 and S3 confirmed that R1 was offered showers two to three times per week and sometimes refused. S1 recounted staff helping R1 with a full shower two days before the ER visit in March. LPA interviewed R2 who shared that "caregivers provided help with personal hygiene as needed according to the care plan". Allegation: Staff do not ensure that the resident has clean clothes — Unsubstantiated W1 shared concerns in emails that R1 was observed wearing soiled or dirty clothes, including one incident on 03/26/2025. The laundry logs and daily care notes indicate that clothing changes were performed regularly and clean clothing was available in R1’s room at the time of visit. S1 stated " incident noted by the home health nurse was attributed to a disconnected catheter, not due to lack of clean clothing". During the investigation visits, LPA toured R1, R2 and R3's rooms and found the rooms to be clean and sanitary. S2 and S4 stated that R1’s laundry was done at least twice weekly and clean clothing was rotated regularly. S2 stated " when the resident cooperated, he was dressed each morning in clean attire". Video evidence provided by W1 showed instances of unkempt appearance but did not clearly establish ongoing pattern of issues related to clothing hygiene. Allegation: Staff are not meeting resident’s hygiene needs — Unsubstantiated W1 expressed concern about R1's hygiene in emails and interviews. LPA's review of ADL documentation, grooming logs, and progress notes confirmed that hygiene tasks, including oral care, changing of briefs, and grooming, were being addressed regularly per care plan. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Entries documented refusals at times, particularly during early morning hours. LPA also toured R1 and R2 and R3’s rooms during visit. LPA observed the rooms were clean and sanitary. S3 and S4 explained that hygiene assistance was offered at least twice daily, and any refusals were documented. S4 noted that grooming tasks were “more difficult when the resident was fatigued or irritable”. LPA interviewed R2 and R3 who did not report hygiene issues among staff. While W1’s observations and concerns are noted, the documentation and interviews do not support a consistent failure in meeting general hygiene needs. Allegation: Resident left in soiled clothing for extended period of time — Unsubstantiated On 03/26/2025, W1’s home health nurse reported that upon arrival at approximately 11:00 AM, R1 was found in wet clothing due to a disconnected catheter. The nurse noted that the resident’s brief and pants were wet, and that R1 declined to be changed at that time. W1 expressed concern that this condition may have been ongoing since 7:00 AM, based on her video monitoring. However, the time of catheter disconnection and when soiling first occurred could not be independently verified. Interviews with S2 and S5 indicated that routine overnight checks were completed and that no visible soiling was observed during their shifts. Progress notes and daily logs for 03/25–03/26 do not reflect any unaddressed episodes of incontinence. While W1's documentation suggests that R1 may have remained in soiled clothing, documentation and staff interviews do not support a finding that R1 was knowingly left in soiled clothing for an extended period of time by staff. This agency has investigated the allegations above. We have found that the allegations were 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 are Unsubstantiated. Exit interview conducted, a copy of this report provided.