complaint·July 26, 2024

The investigation revealed the following: In regards to the allegation: “Staff do not frequently change a resident while in care.” It is alleged that a resident was not being changed. No other information provided. (6) out of (6) staff interviewed denied the allegation and stated that incontinent residents are being changed on a regular basis. S1-S2 stated that they have incontinent schedule/service tracker that’s updated daily. Staff interviewed stated that they have adequate staffing, (2) caregivers per shift plus a 3rd mid shift caregiver. Caregivers follow the service tracker schedule that is provided to them before their shift starts. Some staff interviewed indicated that they monitor the residents and check on them every 2-3 hours or as needed. (6) out of (8) incontinent residents interviewed stated that the staff change them frequently and have not been left throughout the day or overnight without changing undergarments. Residents interviewed stated that staff assist them when they ask for help. Records reviewed revealed that logs are maintained and staff record notes of the care provided to the residents during their shift, whether it's changing undergarments, delivering food or giving the residents a shower. Therefore, there was insufficient evidence to corroborate with this allegation. In regards to the allegation: "Staff are not meeting a resident's hygiene needs." It is alleged that a resident was filthy, no one assists with hygiene and only r eceives a quick and inadequate bed bath from hospice weekly and no other showers / baths. (6) out of (6) staff interviewed denied the allegation and stated that caregivers have a schedule that they follow during their shifts. Facility maintains a daily service tracker, shift to shift report and shower schedule that lists the residents needing assistance in hygiene and shower. Staff interviewed stated that they assist residents with changing clothes, brushing their teeth, feeding and showering. Staff indicated that they give residents a shower 2-3x a week and recorded on the service tracker and shift to shift notes once finished. S2 states that if home health care provides bathing services to a resident, the staff still step in to shower or bathe the resident in between the home health visits. During the visit on 5/21/2024, N1 stated that R1 is being provided bed bath once a week and indicated that hygiene supplies are provided by the facility. LPAs also observed sufficient hygiene supplies stored in the Administration office which are provided to the residents. Records reviewed revealed that R1 is provided shower service by a home health aide and the facility staff. Therefore, there was insufficient evidence to corroborate with this allegation. In regards to the allegation: "Staff did not provide cold water to a resident." It is alleged that there was no cold water in the facility. No other information provided. (6) out of (6) staff interviewed denied the allegation and stated that the facility has cold water but not hot water. Staff interviewed stated that there is no hot water due to a plumbing issue in the community shower rooms and that the water pressure was very low or water only dripped in some stalls. S1 indicated that a plumber already came and provided the estimate. (5) out of (8) residents interviewed stated that only cold water was available and there was no hot water in the shower rooms. During the visit on 5/21/2024, LPA tested the water temperature and readings were 90.8 deg F in stall #1, 98.6 deg F in stall #2 and 89.2 deg F in stall #3, all stalls were in the large community shower room. LPA observed that there was no hot water and a deficiency was issued on a separate case management report. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview and a copy of this report was provided to Alexander Solorio, Asst. Administrator.