Complaint Investigation Report

Staff did not ensure residents room was kept safe, clean, and sanitary

Staff did not ensure residents personal belongings were safely secured

Staff did not ensure residents records were properly maintained

Staff did not ensure residents medications were properly managed

Staff did not ensure residents medications were dispensed as prescribed

Staff did not ensure residents room was kept safe, clean, and sanitary.

W1 reported during a visit the weekend of May 17 , 2024, R1's room was found with the waste basket overflowing with used depends, clothes and papers strewn over the bed, the room hadn't been vacuumed, laundry was undone, the bedding hadn’t been changed, and there was mold growing on R1’s plates that were left in the kitchen sink and open containers of food on the counter tops. S2 stated that it should not had mattered if cleaning is the job of housekeeping, R1’s room was untidy and R1 needed to be relocated for cleaning March 2024. S12 reported that the staff keep reporting things to S1 and nothing was being done, therefore the allegation is substantiated.

Staff did not ensure residents personal belongings were safely secured.

The above allegation refers to the facility not having an adequate policy in place to track residents’ laundry to prevent frequent losses of R1’s clothing which were either never returned or mistakenly worn by other residents according to W1. W1 and S2 stated that on that day of R1’s move-out, the caregivers on duty did not know which laundered items belonged to R1. The items are supposed to be labeled but normally are not, therefore the allegation is substantiated.

Staff did not ensure residents records were properly maintained.

R1 is diabetic and R1’s Functional Evaluation states that the MedTech is to cue R1 to perform a Finger Stick Blood Glucose (FSBG) test twice daily and there’s not any record of performance or denials of FSBG. The document created by S3 to capture R1’s blood sugar, only recorded the dates from 06/24/2024 to 07/23/24 out of the entire time of R1’s residential agreement from 11/22/23 to 08/10/24 therefore the allegation is substantiated.