Complaint Investigation Report

(Continued from LIC9099) On a subsequent visit conducted on 05/09/2025, LPA Rios obtained contact information for R1's home health agency. According to the licensee only the contact information could be provided as an assessment was only recently completed. During visit LPA Rios interviewed one (01) staff and re-interviewed the licensee.

On an annual visit conducted on 05/21/2025 LPA reviewed resident's records and obtained copies, including but not limited to : R1's pre placement appraisal, resident appraisal, physician's report, home heath's plan of care, daily menu, weekly bath schedule.

On a subsequent visit conducted on 08/11/2025, LPA conducted a physical plant tour of the facility. During the tour, LPA re-interviewed the licensee, two (2) out of four (4) residents (R1 and R4), and Resident #4’s (R4’s) family member who was visiting at the time. One resident, admitted in June, was not interviewed as they were not present in the facility when LPA arrived.

Allegation: Licensee does not ensure that resident's grooming needs are met. It is alleged that Resident #1 (R1) is not groomed.

Review of Resident #1’s (R1’s) admission agreement confirmed that grooming was an agreed-upon basic service for which R1 required assistance. During the physical plant tour on 05/07/2025, LPA observed that R1 was not wearing socks, allowing for direct observation of R1’s feet. LPA noted that while R1’s feet were clean, the toenails were long, cracked, and chipped. LPA also observed that R1 had long fingernails. During the interview with R1, the resident spoke generally about their experience at the facility but did not provide information specific to the allegation. Review of physician's report on 05/21/2025 confirmed R1 requires assistance with grooming. In an interview with the licensee conducted today, the licensee stated that R1 had been sent to a podiatrist but acknowledged that staff had not clipped R1’s nails. The licensee explained that R1 required a podiatrist, but added that the facility is now addressing the issue and that "everything is good." LPA requested paperwork for podiatrist visit. Licensee to obtain copies from responsible party and provide copies to LPA. Based on LPA’s observations, interviews, and record review, there is sufficient evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.