Complaint·July 23, 2025

On 04/25/2025, the department received the following documents: Resident Roster (received 04/25/2025), Staff Roster (dated 04/19/2025), All of R1's LIC 601 Identification & Emergency Information - dated 12/14/2022, LIC 602: Physician Report for RCFE - dated 12/19/2022, LIC 603A: Resident Appraisal- dated 12/22/2022, LIC 621:Resident Personal Property & Valuable - dated 12/14/2022, LIC 622:Centrally Stored Medication Record - received 04/25/2025, Residence & Care Agreement - dated 12/14/2022, Resident Assessment - received 04/25/2025, Service Plan - dated 03/25/2025, Resident Care Summary (March 2025) - received 04/25/2025, Medication List (for R1) - received 04/25/2025, Admission Order (dated 12/21/2022, Dietary Order - dated 12/19/2022 & Consent for Alcoholic Beverages - dated 12/19/2022. The investigation revealed the following: Allegation 1 – Staff do not ensure that resident's personal care hygiene needs are met. It is alleged that the facility failed to ensure the resident's personal care hygiene needs are being met. The reporting party stated R1 is not often clean, has not bathed or has been assisted with bathing, teeth cleaned in several days. On 04/25/2025, between the hours of 11:41am -12:15pm, LPA interviewed A1 who denied the allegation. A1 stated that based on the resident service plan for scheduled bathing and or assistance with hygiene is agreed upon from the resident, the resident's family and the facility. A1 states R1 has refused for personal care hygiene which is documented in the progress notes. Most staff confirm that personal care hygiene is provided according to protocol despite resident’s frequent refusals, which are documented and communicated. Some staff not involved or unaware due to role. On 04/25/2025 & 07/23/2025, between the hours of 9:54am - 1:56pm and 8:57am, interviewed 10 staff regarding the allegation:  6 out of 10 staff denied the allegation. 4 out of 10 staff were unaware of the allegation. 3 of staff stated that R1 has refused personal care hygiene multiple times which has been documented and the family has been notified. 4 of the staff stated they never interacted with R1's hygiene only assist with showering the residents who reside on the 2nd, 4th, and 5th 1 of the staff stated only within the first 4 weeks of being hired, she wasn't sure of R1's change in hygiene route or willingness to be assigned to assisted. 3 of the staff stated it's not in their job duties since they are either the facilities the Family Specialist, Housekeeper and or Maintenance. Report continues on LIC 9099-C On 04/25/2025 and 07/23/2025 between the hours of 1:28pm – 3:03pm and 8:28am - 10:40am, the department interviewed residents (R1–R10) about the allegation. 9 out of 10 residents denied the allegation. 1 out of 10 residents did not confirm or deny the allegation. 9 of the residents stated they are independent and don't need assistance personal hygiene care. On 07/08/2025 & 07/22/2025 between the hours of 10:30-2:30pm & 12:25pm - 12:30pm, LPA reviewed R1's LIC 603A, Service Plan and Resident Care Summary and observed the following: under the services need section help with bathing and help with dressing, hair care, and personal hygiene is checked no. In Resident Assessment for bathing R1 needs max full assistance with moderate/max assist with bathing -1 person assist 2x per week (details: shower chair, shower) allow independence, encourage and assist as needed. For grooming needs its moderate with standby assistance for morning/bedtime grooming. For oral care need it is moderate with standby assistance/prepare items(5) with details of assistance with morning/bedtime dental care and wears dentures. The service plan under the exceptions section on 03/04/2025, 03/05/2025, and 03/11/2025 R1 refused bathing after staff tried three times, and R1 become violent towards staff. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the allegation mentioned above. 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. The investigation revealed the following: Allegation 2 – Staff do not ensure that resident is provided clean bedding while in care. It is alleged that the facility isn't providing clean bedding for the resident. The reporting party stated R1 is not often clean and sheets covered in urine and feces. On 04/25/2025, between the hours of 11:41am -12:15pm, LPA interviewed A1 who denied the allegation. A1 stated everyday R1's bedding is checked and changed everyday. A1 also stated if R1's bedding is soiled overnight bedding is always replaced and properly hygiene. On 04/25/2025 & 07/23/2025, between the hours of 9:54am - 1:56pm and 8:57am, interviewed 10 staff regarding the allegation: 7 out of 10 staff denied the allegation stating bedding is changed daily and or as needed. 3 out of 10 staff did not confirm or deny the allegation stated being unaware of how it done and or its not within their job description. The staff such as housekeeping and the family of R1 shared the responsibility for bedding. Bedding is changed regularly according to policy, with immediate changes when soiled. No direct evidence found that clean bedding was not provided. Report continues on LIC 9099-C On 04/25/2025 and 07/23/2025 between the hours of 1:28pm – 3:03pm and 8:28am - 10:40am, the department interviewed residents (R1–R10) about the allegation. 1 of 10 resident confirmed the allegation who stated a delay in replacing soiled sheets. 8 out of 10 residents denied the allegation who stated bedding is changed frequently on a weekly basics. 1 out of 10 residents did not confirm or deny the allegation due to not remembering. On 07/22/2025, between the hours of 1:30pm - 1:40pm, LPA conducted a records review and observed the following: on the service plan, it states under the additional services requested R1's daughter does R1's laundry. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the allegation mentioned above. 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. Allegation 3 – Staff do not safeguard resident’s personal possessions. The investigation revealed the following: It is alleged that the resident's personal possessions are not being safeguarded by the staff. The reporting party stated R1 clothes and jewelry were missing On 04/25/2025, between the hours of 11:41am -12:15pm, LPA interviewed A1 who denied the allegation. A1 stated the LIC 621 is in place for any items would like to safe kept in an area throughout the facility for personal items. For Memory Care all doors are automatically locked. The facility will conduct an investigation if needed by looking at the camera throughout the facility. If staff takes residents personal belonging it’s an immediate termination. Also A1 states R1 has been observed to misplace items and the facility has photo proof. Report continues on LIC 9099-C On 04/25/2025 and 07/23/2025 between the hours of 1:28pm – 3:03pm and 8:28am - 10:40am, the department interviewed residents (R1–R10) about the allegation. 3 out of 10 staff denied the allegation. 7 of 10 staff did not confirm or deny the allegation. 1 of the staff emphasize being made aware of R1's missing items due misplacing their personal belongings such as shoes and or undergarments which were later found. On 04/25/2025 and 07/23/2025 between the hours of 1:28pm – 3:03pm and 8:28am - 10:40am, the department interviewed residents (R1–R10) about the allegation. 1 out of 10 resident confirmed the allegation. 8 out of 10 residents denied the allegation. 1 out of 10 residents did not confirm or deny the allegation. 1 of the residents stated money and jewelry were stolen by staff. 8 of the residents stated no having an issues with their personal items missing as the resident keep track of their own belongings. 07/22/2025, between the hours of 1:30pm - 1:40pm, LPA conducted a records review of R1's LIC 621 Client/Resident Personal Property and Valuables dated on 12/14/2022 which stated a silver watch and a gold watched are located in a jewelry box. On 07/23/2025, at the time of LPA concluding interviews, LPA was unable to follow up with R1 in regards to this matter due to R1 no longer resides at the facility as of May 2025. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the allegation mentioned above. 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. No deficiencies were cited for this allegations . An exit interview was conducted, and a copy of this report was provided to Vanita Harris, Business Office Manager