Complaint·December 13, 2024

It was alleged that R1 is often left alone in their room in the dark, their hygiene needs are not yet, they lost significant weight, and are declining rapidly. LPA interviewed a witness who stated there are no major concerns with R1’s hygiene, they do not know if R1 has lost weight since entering the facility, and that R1 has declined rapidly but R1’s decline may be a consequence of their diagnosis. LPA conducted a health and safety check on R1 and LPA’s observations of R1 did not corroborate the allegation. LPA interviewed R1 and did not obtain information corroborating the allegation. LPA conducted health and safety checks on and interviews with 19 additional residents and did not obtain information corroborating the allegation. LPA interviewed AD who denied the allegation, stating that R1 sometimes chooses to be in their room and locks their door, there have been no reports of hygiene issues with R1, that R1 has not lost weight, and that R1’s care needs have increased solely due to mental health concerns and not physical health. LPA reviewed R1’s Assisted Living Waiver Assessment dated May 16, 2024, which states that R1 weighs 115 pounds. During the inspection, LPA observed a staff member weigh R1 and noted R1 currently weighs 128 pounds, which indicates R1 gained weight while at the facility. LPA reviewed R1’s Assisted Living Waiver Individual Services Plan dated May 16, 2024, which indicates R1’s care needs are Tier 2. LPA interviewed R1’s Assisted Living Waiver care coordinator who stated that R1 was reassessed as Tier 4 due to decreasing cognitive ability and now needing redirection with all activities of daily living. No information was obtained showing that R1’s cognitive decline was caused by lack of care and supervision by the facility. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.