Complaint·April 2, 2025

Staff did not keep the facility clean, sanitary and free from odor The department investigated allegation, “Staff did not keep the facility clean, sanitary, and free from odor. LPA interviewed staff, relevant parties, witnesses, and reviewed facility records. Interviews indicated that R1’s room had strong smells of urine. LPA interviewed care staff in which they stated resident was incontinent and would have accidents. Care staff stated they would clean resident and residents’ room and give R1 showers when needed. LPA interviewed R1’s family in which they stated they observed R1’s bathroom being unclean and R1’s bathroom having a smell of urine to it. LPA interviewed a witness, and they stated resident’s room smelled strongly of urine and was unclean. LPA observed on outside agency documentation that resident bed was unclean and window had to be opened due to the smell. Based on interviews conducted and observations, staff did not ensure the facility was kept sanitary and odor free. Staff did not report a change in resident's condition. The department investigated allegation, “Staff did not report a change in resident’s condition”. LPA interviewed staff, relevant parties, witnesses and reviewed facility, and hospice records. Interviews indicated R1 lost 30 pounds between the month of March 2024 to June 2024. Facility did not report weight loss to R1’s primary care physician or responsible party. LPA interviewed facility staff in which they stated they did not observe R1 having wight loss during their stay at the facility. Interviews with the memory care director indicated staff weigh residents monthly and will report changes to doctor and responsible party if necessary. Memory care director stated there was nothing significant to report to family. LPA reviewed hospice documents in which it states R1 weighed 206 pounds in January 2024 and her last recorded weight in June 2024 was 176 pounds. R1 lost 30 pounds in 6 months. Based on information obtained, R1 was found to have lost 30 pounds in 6 months and facility did not report the change to R1’s primary care physician or R1’s responsible party. Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.