Complaint Investigation Report

LPA obtained copies of staff schedules, LIC501 Personnel Records and resident roster. LPA also interviewed the following: staff (S1, S2) and former Executive Director (FED) on 11/28/23; resident’s family member (W1) on 12/05/23; R1 and R3’s family member (FM1) and staff (S3 and S4) on 5/27/25.

It was reported that resident (R1) passed away on 11/19/23 because the facility did not seek timely medical assistance.

S1 stated when she went to R1’s room sometime between 11/06/23 and 11/08/23 and observed R1 pale and not responsive, she called 9-11. R1 was sent out and diagnosed with infection. Records confirmed R1 was sent out to the hospital. Records also showed R1 was placed on hospice on 11/10/23 with terminal diagnosis of cerebrovascular disease. Death certificate showed immediate cause of death as cerebrovascular disease, Parkinson’s disease, adult failure to thrive and no other significant conditions contributing to R1’s death. Based on information gathered, the allegation is closed as unsubstantiated.

Allegation: Staff are not assisting residents with bathing needs.

S1 stated that R2 has not been showered for a month. S2 indicated that bathing is included in the resident’s Care Plan and the frequency depends on the Care Plan. S3 and S4 stated they give bath to residents 2 times per week. FM1 stated she visited R1 and R3 when they were at the facility and stated R1 and R3 were bathe 2 times per week.

Review of bathing schedules showed R1 on the list on a once-a-week schedule. R2 was listed on twice-a- week schedule. LPA was not able to interview R1 and R3 due to these residents were no longer at the facility when complaint was received. Due R2’s medical diagnosis, LPA was also unable to obtain information. LPA tried to reach R2’s responsible person but was unsuccessful. Therefore, the allegation is unsubstantiated. .......continued on 9099C (page 3)