Complaint·June 27, 2023

R1 was admitted to the facility on 01/31/2022. Facility observation log from 1/31/2022 – 6/2022 noted change in R1’s condition and service were provide accordingly. Staff interviewed reported that upon move in on 01/31/2022, R1 only needed verbal reminders with toileting, brushing teeth, bathing, and dressing. Staff reported noticing a decline in R1's condition from 02/2022 to 3/2022. According to staff R1's change in condition was always communicated to the responsible person. Facility observation notes from 02/2022 – 6/2022 and care plan dated 9/1/2022 revealed that R1 was easily agitated, combative at times and uncooperative. Staff reported that R1 would not cooperate with brushing and using water pick to clean teeth as the family requested. A tour of the Memory care unit was conducted during the subsequent visit on 1/24/2023, with the Administrator from approximately 3:30 p.m. – 4 p.m. Random residents observed in the Memory Care unit appeared to be clean and dry. LPA made an attempt to interview five (5) residents in the Memory Care unit. Other potential witnesses interviewed during the course of investigation reported being satisfied with the care services. Based on the information obtained through interviews and records review, there is not enough evidence to support allegations. Therefore, the allegations are deemed Unsubstantiated at this time. Exit interview held, copy of report issued. Additional staff and resident interviews were conducted on 01/24/2023 from 2:30 p.m. - 3:15 p.m. Also, during the initial and subsequent visits facility records were reviewed. Records dated 10/21/2021, noted that R1 was confused/disoriented however, able to follow instructions; able to feed self and care for own toileting and hygiene needs. R1 was admitted to the facility on 01/31/2022. Facility observation log from 1/31/2022 – 6/2022, noted change in R1’s condition and increased/additional service provide. Staff interviewed reported that upon move in, R1 only needed verbal reminders with toileting, bathing, and dressing. Staff reported noticing a decline in R1's condition from 02/2022 to 3/2022. According to staff, R1's change in condition was always communicated to the responsible person. Staff reported that R1 was monitored daily at least every 2 hours for incontinent care needs. According to the staff no resident is purposely left in soiled clothing. Staff stated that incontinent care residents are checked in the mornings, before and after each mealtime, and at least every 2 hours day/night. Allegation: Staff did not properly monitor a resident's change in medical condition. Information was received that R1 went to the hospital due to uncontrolled nosebleed on 4/3/2022. R1 returned from the hospital with nose plug to stay in for two (2) days. It’s alleged that staff did not follow through with monitoring R1 and as a result R1’s nose plugs were observed pulled out the next morning. Staff interviewed on 09/08/2022 and 01/31/2023 did not recall this incident. Staff reported that R1 was constantly agitated and at times combative. Staff reported that R1 was monitored night and day, every 2 hours. Facility observation notes dated 04/01/2022 noted that R1 was observed by staff in the hallway with apparent nosebleed; R1’s face was cleaned, and nose had stopped bleeding; R1 was monitored, and family was informed. There was no charting recorded for 4/2/2022 and 4/3/2022 for R1. On 4/4/2022 facility observation log noted: R1 was on monitoring for bloody nose; nose packed with gauze, minimal of blood noted; continued to monitor; 4/6/2022 charting indicates no blood in nostril; continue to monitor. No other charting regarding R1’s nosebleed was noted. According to staff, R1’s change in medical condition from move in was always communicated to R1’s physician and responsible person. Allegation: Resident hygiene needs not met. Regarding this allegation there was concern that facility staff are not following through with brushing R1’s teeth and using a water pick. During the initial visit on 09/08/2022, LPA conducted interviews with facility staff, and administrator at approximately 4:45 p.m. Additional staff and resident interviews were conducted on 01/24/2023 from 2:30 p.m. - 3:15 p.m. Also, during the initial and subsequent visits facility records were reviewed. Records dated 10/21/2021, noted that R1 was confused/disoriented however able to follow instructions and care for own hygiene needs.