complaint·January 15, 2025

The investigation revealed the following: Regarding the allegation “staff are not ensuring residents have clean linens”, it is being alleged that residents’ linens are soiled. Interviews conducted revealed the following: 11 out of 11 residents denied the allegation and 5 out of 5 staff denied the allegation. Observations revealed the following: the department toured 7 resident rooms and did not observe soiled linens. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff are not assisting residents with changing clothes”, it is being alleged that staff are not assisting residents in changing clothes (e.g. soiled clothing). Interviews conducted revealed the following: 11 out of 11 residents denied the allegation and 5 out of 5 staff denied the allegation. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff are not assisting residents with showers”, it is being alleged that staff are not assisting residents with showers. Interviews conducted revealed the following: 11 out of 11 residents denied the allegation and 5 out of 5 staff denied the allegation. Records reviewed revealed the following: the facility has a Shower Schedule which describes residents who require assistance, reminders, stand by, independent, etc. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff are not assisting residents with medications timely”, it is being alleged that staff are not providing residents with their medication in a timely manner. Interviews conducted revealed the following: 10 out of 11 residents denied the allegation and 5 out of 5 staff denied the allegation. Records reviewed revealed the following: 5 out of 5 Medication Administration Records (MARs) indicate that medications were provided to residents during the prescribed time frame. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff do not assist resident with follow-up medical appointments”, it is being alleged that staff refuse to assist residents with follow-up medical appointments. Interviews conducted revealed the following: 10 out of 11 residents denied the allegation and 5 out of 5 staff denied the allegation. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. No citations were issued. An exit interview was conducted, and a copy of this report was left with the Quality Assurance Director.