Complaint Investigation Report

LPA was unable to interview R1 due to not residing at the facility. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed an in service of updated staff training dated September 16, 2025, that covered topics of preventing bruising/pressure injuries.

Regarding the facility allegation of medications are accessible to residents in care and facility is falsifying medication log revealed the following: It was alleged that staff are leaving medications in a room unattended making the medication accessible to residents in care and that facility staff threw away medication after a resident refused to take it, but told staff that it had been administered. Interviews with three of three staff revealed that the facility nurse is the only one that passes medications and marks off the medication log and that they stand there and ensure the resident takes their medications before moving on. Three of three staff could not recall a time where medications were ever accessible to residents in care or when the medication log had been falsified. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed a medication security policy that was reviewed and signed by facility staff on March 27, 2025 and April 1, 2025. LPA reviewed resident medication and observed it to be administered according to physicians orders at the time of the investigation using the facility electronic medication administration record.

Regarding the facility allegation of residents hygiene needs are not being met revealed the following: It was alleged that residents were not given showers for three weeks. Two of three staff informed LPA that when a resident refuses to take a shower, they will try again later. If the resident keeps refusing, they will try again on the next shift. Two of three staff informed LPA that they will keep asking the resident, but will not force them to take a shower. LPA did not observe shower logs for residents in care. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed staff training covering bathing a person with dementia last done in the year 2024 for three of three staff.

Regarding the facility allegation of residents bedding is left soiled for a long period of time revealed the following: It was alleged that facility staff left Resident #2(R2) in their soiled bed for three weeks. LPA reviewed a physicians report dated January 1, 2023, stating that R2 was diagnosed with dementia, does not require continuous bed care, did not have bladder or bowel impairment, was unable to communicate their needs, was able to care for their own toileting needs and was considered non ambulatory. Two of three staff informed LPA that residents are checked for brief changes every two hours unless needing a changing sooner. Two of three staff informed LPA that caregivers are able to change residents sheets even if they are still in the bed. Two of three staff informed LPA that R2 was difficult to change, but the staff never left them soiled for an extended period of time. Continue on 9099C