Complaint Investigation Report

Allegation: Facility staff are not assisting resident with showering needs. It is alleged that resident (R1) was not being showered at least two times per week in July 2020 by facility staff. According to staff interviews, residents are to be showered two times per week and/or as needed. The resident was enrolled in home health but due to the COVID-19 pandemic home health staff were not providing shower assistance.

A total of 10 residents were interviewed, of which four (4) out of 10 residents stated they were not shower at least two times per week between June 2020- July 2020. A total of 10 staff were interviewed. One (1) staff stated that due to the pandemic staffing shortages caregiver staff were not able to shower their assigned residents, and the evening and weekend shift staff did not assist with showers. Per shower record review, R1's was showered regularly.

Allegation: Facility staff do not allow resident to leave their room. It is alleged that resident (R1) was quarantined in it's room due to bed bugs, and as staff mistreatment for not paying rent. Per staff interviews, resident (R1) was quarantined in it's room as a result of skin irritation. Staff handled the situation as a potential shingles outbreak and requested R1 isolate in it's room. Per MD appraisal it was determined not to be the shingles virus. The resident was treated with cream treatment during it's quarantine. One (1) out of 10 residents stated they were not allowed to leave their room. Staff interviews confirmed R1 was quarantined in it's room as a precautionary infection control measure related to possible shingles diagnosis, and not due to bed bugs in it's room. Staff stated that during bed bug room heat treatment residents are always moved out of the room, and in particular this resident was moved out of it's room when the room was treated.

Allegation: Facility staff are not keeping the resident's room clean. It is alleged that R1's room was not being cleaned, and was only cleaned once between July 19, 2020- July 27, 2020. During these dates, R1's room had bed bugs and allegedly never received steam cleaning/heat treatment nor was it's mattress changed. Nine (9) out of 10 resident interviews stated that their room is cleaned daily and reported no issues with room cleanliness or housekeeping. All staff stated that resident rooms are cleaned everyday by housekeeping staff, and in instances of staff shortages caregivers assume general room clean up i.e. taking trash out and cleaning of floors. Staff stated that resident rooms are especially cleaned after bed bug treatment. Housekeeping daily responsibilities are mopping room floors daily, making resident's beds, and cleaning the bathrooms. On days, that housekeeping staff are off other housekeepers are responsible for the tasks.

The findings indicate that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview and a copy of the report was issued to Administrator Nirjana Acharya.