Complaint·October 17, 2025

On 03/25/2025, R1 sustained another fall, and again received emergency medical attention. Hospital discharge instructions recommended follow-up care with a PCP or orthopedic specialist. While follow-up appointments were recommended in both instances, records confirmed that R1 did not attend the follow-up visits. Interviews and records revealed that R1 has a Durable Power of Attorney for Health Care and Finances, executed on 08/13/2022, which grants the RP full authority over R1’s healthcare decisions. The facility did notify R1’s responsible party of both incidents. In a statement, RP stated that RP resides out of state and acknowledged being unable to arrange follow-up care, despite being aware of their legal authority and responsibility and was notified of the incidents. In an interview with 4 out of 4 facility staff all denied that R1 staff did not seek timely medical attention to R1. In an interview with 7 out of 7 residents who all stated no concerns with facility staff, not providing timely medical attention to residents in care. Additionally, R1’s responsible party expressed no concerns about the care being provided and stated that the facility staff are doing their best. Based on interviews and records review during the investigation process LPA Lee was unable to corroborate the allegation. It was alleged that staff are not meeting residents’ personal hygiene needs. The investigation included observations, record reviews, and interviews with staff, residents in care and a resident’s responsible party. During facility visits on 07/10/2025 and 10/03/2025, LPA Lee observed residents in the memory care unit to be groomed, with no signs of unmet personal hygiene needs. Review of R1’s chart notes and shower logs indicated that activities of daily living (ADLs), including showering and dressing, were being completed despite R1 exhibiting agitation and violent behavior. Moreover, R1 were sent to the hospital on 02/06/2025 due to anxiety and were discharged with a diagnosis of behavioral disturbance. Documentation revealed that R1 occasionally refused showers and being changed. Three staff interviews indicated that R1’s personal hygiene care was being provided, although care was brief due to R1’s agitation and aggression and that R1 occasionally refused showers and being changed. Interviews with 7 out of 7 residents who stated no concerns about their personal hygiene’s needs not being met by facility staff. Moreover, in an interview with R2’s responsible party who occasionally visits R2 has no concern with their family member’s personal hygiene needs not being met. Additionally, R1’s responsible party expressed no concerns about the care being provided and stated that the facility staff are doing their best. Based on interviews and records review during the investigation process LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.