Complaint Investigation Report

On the allegations that staff were not showering residents, Staff are not ensuring the residents are properly dressed and groomed, Staff allow the residents to sleep on wet and dirty sheets, Staff did not properly report an incident involving a resident , and Staff are not meeting the residents diabetic needs the following was found:

Interviews and document reviews confirmed that residents were not consistently receiving showers. End-of-shift reports documented that showers had been completed, but this conflicted with observations recorded in disciplinary documentation. Memory Care Director stated that they had received complaints from staff regarding inconsistent hygiene practices and personally observed residents who had not been bathed. Memory Care Director also reported that S2 “would lie and say she tried to shower residents but wouldn’t follow through.” Disciplinary documentation issued to S2 on 01/23/25 confirmed that Resident was observed with a soiled bed, a soiled brief on the floor, and a soiled comforter nearby. S2 received a final written warning as a result. Similarly, S3 received a final written warning dated 01/24/25 after Resident was found following an unwitnessed fall with blood in the shower, urine on the sheets and bed protector, and a dirty brief under the sink. The room had not been cleaned. These incidents were formally documented and observed by facility management.

Residents were also not consistently groomed or dressed. Memory Care Director reported having observed multiple residents still in pajamas late into the day and confirmed that some staff were not assisting residents with dressing. It was also reported that there were residents that were have found put in bed with their daytime clothing and not dressed out for bed at night. Documentation further supported that residents were allowed to sleep on wet and dirty bedding. The disciplinary notice for S2 referenced a resident found in a soiled bed with visibly unclean linens. The notice for S3 detailed the condition of a resident room where urine and blood were present, and incontinence items had not been disposed of. These were documented observations that resulted in disciplinary action. Memory Care Director also confirmed knowledge of incidents where residents bedding was left soiled by staff.