Complaint Investigation Report

Allegation: Resident’s room is unsanitary

W1 stated she reported these conditions to executive director (ED) who stated he would handle with staff. W1 visited R1 again on 12/01/21 with the bathroom in the same unsanitary condition, stained rugs not removed and washed. On 01/22/22, W1 visited R1 and found poop on the toilet and pajamas full of poop thrown in the shower. Based on interviews and record reviews which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that resident’s room is unsanitary was found to be substantiated.

Allegation: Resident’s hygiene needs are not being met

During investigation, witness (W1) stated family visited resident (R1) at the facility on several dates (11/30/21, 12/06,21) and reported to staff that R1 had not had a shower with hair greasy. W1 stated R1 was finally showered by staff on 12/07/21. W1 stated that from 12/10/21 until 12/13/21, R1 was again not given a shower. ED stated a care conference was held with W1 and R1’s family on 12/15/21. R1’s shower schedule was discussed as well as R1’s weight loss and meal menu. W1 stated staff showered R1 on 01/06/22. Review of R1’s care plan showed R1 required full assistance with weekly showering, wash, shampoo and dressing/undressing to maintain good personal hygiene and cleanliness. On 02/12/22, W1 stated she visited R1 and found her hair greasy again, she had no underwear on and was full of poop. W1 stated the bathroom floor had dried poop and asked staff to clean the room asap. Rather than wait for staff to show up, W1 and W2 stated they gave R1 a shower, washed her hair and placed clean underwear on her and fresh clothes.