Complaint·February 11, 2025

CONTINUED FROM LIC9099-A Regarding the allegation that Staff did not assist residents with mobility needs in a timely manner , the following has been concluded: Based on eight interviews conducted with facility residents along with tours of the physical plant, all residents with limited mobility met or observed were fully able to access the facility's call system from their bed. A majority of residents interviewed either stated no concerns with facility staff response time or stated that they were satisfied with response times. Regarding the allegation that Staff did not ensure resident’s showering needs were met , the following has been concluded: During a total of eight resident interviews conducted, a majority of residents stated that they received adequate assistance for their personal toileting care and expressed no complaints with the frequency of the showers provided by facility staff. As a result, both allegations are found to be Unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and a copy of the report provided. CONTINUED FROM FORM LIC9099 Regarding the allegation that Licensee used full bed rails for non-hospice resident , the following has been concluded: During the initial complaint investigation visit conducted on November 20, 2024, licensing staff observed resident R1 was placed in a hospital bed equipped with half-rails that were positioned lower than the head of the bed. Once the upper part of the bed frame became elevated, it was observed that the half-rails functioned the way full-length rails would. Based on interviews conducted and files reviewed, R1 was confirmed to not be received hospice care at the time of the visit. Regarding the allegation that Staff did not ensure resident was provided with adequate bed linens , the following has been concluded: Based on observation made during the initial complaint investigation visit, R1 had mobility issues related to a surgical intervention and was placed in a hospital bed. During the visit, linen were observed to be crumpled up underneath the resident, leaving the resident to lay on a bare mattress. As a result of both observations, the allegations are found to be Substantiated, meaning that the preponderance of evidence has been met. Deficiencies cited on an attached form LIC9099-D. An exit interview was conducted with facility staff and a copy of this report along with appeal rights were provided to a facility representative.