complaint·July 26, 2023

Page 2 Regarding the allegation: Staff failed to meet resident's incontinent needs and staff failed to meet resident's hygiene and grooming needs. It was alleged that staff would leave Resident #1 (R1) soiled. A review of R1’s charting notes indicated that at times, R1 would not allow staff to assist with care. However, staff indicated that they would either ask another care staff for assistance, return at a later time to assist R1 when R1 was ready, and would ensure that they informed management and R1’s responsible party. Staff indicated that residents that required assistance with toileting were checked and changed at least every two (2) hours. Staff who provided care to R1 indicated that R1 would oftentimes refuse care and would act aggressively towards staff, but staff denied claims that R1 was ever left soiled. Staff also claimed that oftentimes, they had to use two (2) staff to provide care to R1, as R1 would oftentimes become aggressive when receiving care. Staff would also document the times in which R1 would refuse care. During the physical plant tour on 3/20/2023 and 7/26/2023, residents appeared well groomed. The LPA’s did not smell any odors nor did residents indicate that staff failed to meet their incontinent needs. Residents also denied claims that they had ever been left soiled for an extended period of time. The LPA attempted to reach out to R1’s family for additional information, but the LPA did not receive a response. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to meet resident's incontinent needs or the claim that staff failed to meet resident's hygiene and grooming needs. These allegations are deemed Unsubstantiated at this time. Regarding the allegation: Staff isolated resident in care It was alleged that R1 had not left their room in ‘a long time’. During the physical plant tour on 3/20/2023 and 7/26/2023, the LPAs observed that many residents in the memory care unit were congregating in the common living room. Staff supported claims that they encouraged residents to leave their room for activities, but also respected if residents wanted to stay in their room for personal reasons. Staff stated that R1 would oftentimes opt to stay in the room, but also indicated that R1 was found to participate in certain communal activities. Residents did not indicate that they ever felt isolated in the community and stated that there were many activities to participate in. The LPA interviewed five (5) residents in the memory care unit, whom communicated no concerns and did not indicate that they were ever forced to stay in their room or were isolated from activities. Based on the information obtained, there is insufficient evidence to support the claim that staff isolated R1.This allegation is deemed Unsubstantiated at this time. Page 3 Regarding the allegation: Facility has insufficient staffing to meet residents' needs It was alleged that there were not enough staff in the memory care unit. Interviews and records indicated that fully staffed meant there were at least three caregivers for the AM shift and PM shift, not including a medication technician. Staffing is also based on the needs of the current residents within the facility. Staff admitted that at times, if someone calls off, staff will need to supplement with agency staff, assign a medication technician to also conduct caregiving duties, or management staff will step in. Although some staff indicated that additional staff members were needed, the majority of staff felt that there was sufficient coverage to manage resident care needs. Similarly, most residents interviewed indicated that care needs have not suffered or gone un-met due to staffing concerns. Based on the information obtained in interviews and record review, there is insufficient evidence to support the claim that facility has insufficient staff for residents while in care. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Resident rooms are malodorous It was alleged that rooms smelled of excrement. During the physical plant tour conducted on 03/20/2023, the LPA’s toured all thirteen (13) rooms in the memory care unit. Rooms appeared clean, well kempt, and did not smell of any odor. The LPAs did not observe any soiled furniture, and resident furniture appeared clean and in good condition. During the physical plant tour conducted today, the LPA again found rooms to be clean and did not observe any unpleasant odors in either the memory care unit or assisted living rooms. Residents indicated that rooms were cleaned on a weekly basis, and both staff and residents indicated that if rooms required extra cleaning, housekeeping would be alerted. Based on the information obtained, there is insufficient evidence to support the claim that resident rooms are malodorous. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff failed to keep the resident's room clean It was alleged that staff allowed R1’s trash can to overflow, and that R1’s room overall appeared unclean. Staff whom provided care to R1 claimed that R1 and all residents received weekly housekeeping services. Staff said that if R1 ever asked them to leave the room, they would do so, but staff would also ensure that R1’s room was cleaned regularly. Page 4 During the physical plant tour conducted on 03/20/2023, the LPA’s toured all thirteen (13) rooms in the memory care unit. Rooms appeared clean, and well kempt. During the physical plant tour conducted today, the LPA again found rooms to be clean in both the memory care unit and assisted living rooms. Residents indicated that rooms were cleaned on a weekly basis, and both staff and residents indicated that if rooms required extra cleaning, housekeeping would be alerted. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to keep R1's room clean. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility is unclean and unkempt It was alleged that the facility was unclean. Staff claimed that common spaces were cleaned on a daily basis, and that resident rooms received housekeeping services at least once a week. During the physical plant tour conducted on 03/20/2023, the LPA’s toured all thirteen (13) rooms in the memory care unit, including the common spaces. Rooms appeared clean, and well kempt. During the physical plant tour conducted today, the LPA again found rooms to be clean in both the memory care unit and assisted living rooms. Residents indicated that rooms were cleaned on a weekly basis, and both staff and residents indicated that if rooms required extra cleaning, housekeeping would be alerted. Interviews with ten (10) residents during today’s visit revealed housekeeping services are provided once a week and there are no issues or concerns regarding services not being provided as scheduled. Interviews with staff revealed residents are provided housekeeping services weekly. Based on the information obtained, there is insufficient evidence to support the claim that the facility is unclean and unkempt. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.