Complaint·August 11, 2023

Allegation: Staff left resident in soiled sheets for an extended period of time Investigation Finding: Unsubstantiated Continuation... Review of R1’s care plan show staff provided R1 full assistance with R1’s bathing/showering (2X per week) and daily assistance with dressing/undressing, toileting and wandering. Review of R1’s care plan also showed daily routine checks done by staff every 2 hours as instructed by hospice care team. Based on interviews and record reviews which were conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff left resident in soiled sheets for an extended period of time is unsubstantiated. Allegation: Staff are not meeting resident’ s care needs Investigation Finding: Unsubstantiated During investigation, LPA reviewed R1’s care plan dated 04/20/2022 which showed nail care was provided by a certified podiatrist every month on the 31 st day or as needed since R1 was a high risk for complications following nail care. ED stated R1 left the facility 05/24/22 and moved to another facility. ED stated R1’s authorized representative met with him in May 2022 because they wanted to move R1 back to the facility due to better care than the facility they moved R1 into. Based on interviews and record reviews which were conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff are not meeting resident’s care needs is unsubstantiated. Allegation: Facility is short staffed Investigation Finding: Unsubstantiated During investigation LPA observed the memory care unit has 24 dementia residents assisted by 4 staff (2 caregivers, 1 activities assistant and 1 resident care director) on each shift. Residents in care were observed well groomed, odor free and comfortable in their surroundings. Review of R1’s care plan dated 04/20/22 show staff provided R1 full assistance with activities of daily living - bathing (2X per week); toileting, dressing/undressing, grooming, incontinence care, wandering daily with routine checks done every 2 hours as well as implemented hospice care teams’ instructions while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility is short staffed is unsubstantiated. Exit Interview conducted and a copy of this report provided.