Complaint·February 11, 2025

LPA reviewed the Service Plan and observed that the resident was on Level II care that required no assistance as it relates to transfers and mobility. In addition, the Service Plan was signed and dated on December 10, 2024, by the Responsible Party. LPA reviewed the call bell log for the date in question and observed that the resident did not press the call pendent or alert staff. During a review of the Medical Records on January 22, 2025, LPA learned that the resident was on the commode for 7 hours. However, the hospital could not determine what caused the resident to be on the commode for that long. On January 21, 2025, LPA conducted a collateral interview with Resident #1 but could not obtain additional information as to what occurred. During interviews, LPA received inconsistent statements as it relates to the allegations. LPA could not corroborate the allegations. Complaint alleges Staff did not ensure that a resident was provided meals and water. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. Furthermore, during interviewing, LPA learned of no concerns as it relates to the food service at the facility. LPA could not corroborate the allegation. Complaint alleges Staff did not ensure that resident's clothing was changed. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. Furthermore, during interviewing, LPA learned of no concerns as it relates to the changing of resident’s clothing. LPA could not corroborate the allegation. A finding that the complaint allegations of: Staff did not prevent a resident from developing pressure injuries while in care, Staff left a resident on a toilet for a long period of time, Staff did not ensure that a resident was provided meals and water, Staff did not ensure that resident's clothing was changed are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Med Tech.