Complaint·May 8, 2025

R1's Assessment conducted on November 21, 2024, and R1's Individualized Service Plan, dated November 21, 2024, indicated that R1 required complete assistance with toileting needs and has difficulty maintaining acceptable hygiene standards. R1 required hands on assistance with all grooming and hygiene tasks. R1 required total assistance and/or an additional caregiver for all showering/bathing needs 3-4 times per week. R1 required total assistance with dressing and undressing and assistance with clothes selection 2 times per day. R1 also required hands on assistance with cleaning and/or storing dentures in appropriate container. According to the December 2024 Staff Assignments log, staff initialed each time they aided with toileting according to schedule, need and requests, as well as ordering and maintaining inventory of incontinence products, clothing and linen according to need. Staff also initialed each time they aided with grooming, bathing, dressing, and denture care. The only missing entries were when R1 was hospitalized. R1's Assessment conducted on November 21, 2024, and R1's Individualized Service Plan, dated November 21, 2024, indicated that R1 expresses frustration or reluctance when receiving assistance with Activities of Daily Living (ADLs) but generally cooperates, minimal staff time is needed. Interviews with staff (S2) and S3 indicated that it was difficult for care staff to provide R1 assistance with ADLs. S2 and S3 indicated that R1 would become combative, however, they were still able to provide R1 care. S3 and staff (S4) indicated that, when it is difficult to provide care to a resident, the care staff team up to assist each other in providing care. W1 indicated that facility provides all care needs. R2, R3, R4, R5, R6, and R7 indicated that they are receiving assistance with all their care needs from facility staff. Home Health Nurse indicated that R1 didn't seem unkept. Home Health Nurse indicated that they never conducted a urine analysis when R1 resided at the facility. According to facility Charting Notes, R1 was sent to the hospital on December 9, 2024, returning the same day with a UTI and a prescription for antibiotics. Emergency Department records, dated December 9, 2024, indicated that R1 sustained a fall at the facility. Records indicated that there was no evidence of injury, however, they were awaiting urine analysis results for suspected UTI. Records indicated that an antibiotic was started for potential UTI in the Emergency Department and a new prescription was ordered to continue medication upon discharge. Facility Charting Notes indicated that, on the evening of December 10, 2024, R1 had shortness of breath and was wheezing *******************************************Continued on LIC9099-C****************************************************** so was sent to the hospital. After Visit Summary, dated December 15, 2024, indicated that R1 was admitted on December 10, 2024, and discharged on December 15, 2024. R1 was found to have COPD exacerbation with associated severe sepsis. R1 was started on additional medication. Upon discharge from the hospital, R1’s COPD exacerbation and associated severe sepsis had resolved. Based on medication count, interviews conducted, and documentation obtained, 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. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.