complaint·July 28, 2023

Therefore, LPA finds that the allegation is unsubstantiated. Regarding the allegation that Resident's jewelry went missing while in care at the facility. LPA spoke with staff and witnesses and reviewed files. LPA was not able to find any staff who had any knowledge of the jewelry in question. Therefore, LPA cannot say what might have happened. Items such as small jewelry can become easily lost, misplaced, accidentally thrown away, etc., especially in memory care as individuals may not remember what they did with an item or if someone else was involved. Therefore, allegation is unsubstantiated. Regarding the allegation that Facility staff did not ensure proper placement and use of resident's hearing aids. LPA has spoken with staff. It appears that staff made attempts to place hearing aids in the ears of R1 each morning. Staff stated that they would only place the aids if R1 was up and out of bed. If someone came to visit early, it is possible that R1 was not out of bed yet, or staff had not had a chance to help him yet. LPA is not able to say that staff was or was not neglectful or forgetful or that they were not attempting to assist. Therefore, allegation is unsubstantiated. Regarding the allegation that Facility staff did not keep resident's room clean of fecal matter. LPA has spoken with staff, witnesses and toured the facility. On the date of my unannounced visit LPA found the rooms to be clean and free of odor. LPA learned that it’s possible that staff may have assisted R1 to get clean and ready in the morning, and then after breakfast he could go to his room and have an accident which he would try to take care of. It’s possible that someone could have found this situation before staff had a chance to check on him. Therefore, LPA is not able to say that staff was in any way neglectful of R1’s hygiene. Allegation is unsubstantiated. Regarding the allegation that Facility staff did not meet resident's hygiene needs. LPA spoke staff and learned that R1 had showers several times per week and more often when needed. As above, R1 would apparently try to take care of things himself, and may have not been clean when someone visited. Again, LPA is not able to say this was because of neglect on the part of staff. Allegation is unsubstantiated. Regarding the allegation that Facility staff did not assist residents while eating. LPA interviewed staff and watched meals. LPA learned that staff try to encourage residents to be as independent as possible when eating; and will assist if the resident really needed. Again, LPA is not able to say if someone really did or did not get assistance when needed. Allegation is unsubstantiated. Regarding the allegation that Facility staff did not meet resident's laundering needs. Through interviews with staff LPA learned that laundry is generally done once a week for each resident, and more often if needed. If clothes/bedding are wet or soiled, staff will take it out and wash it. As above, LPA learned that R1 would try to be independent and would sometimes change himself, then put wet or soiled clothes into his hamper. It is possible that this was done and staff did not immediately find the soiled laundry. However, LPA is not able to say staff was neglectful. Allegation is unsubstantiated. Regarding the allegation that Resident was made to sleep in urine-stained bed sheets and mattress, LPA interviewed staff and learned that R1 was in the habit of making his own bed. He would apparently do this even if the sheets were wet/soiled and needed to be changed. Therefore, it is possible that visitors could have found a bed that had been “made” but still had wet sheets. LPA cannot say that staff was neglectful in this case. Allegation is unsubstantiated. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted; appeal rights provided.