Complaint Investigation Report

Per R1’s LIC602, there was no mention of hospice being recommended. Five out of five staff stated R1 was not on hospice. LPA reviewed R1’s head-to-toe assessment dated April 3, 2026, and photos of bruises on R1’s legs and arm. Per shower body check forms dated April 7, April 10, April 17, April 21, April 24, April 28, May 1, and May 5, 2026, no abnormalities on the skin were noted by caregiver. Photographic evidence shows bruise on left calf and bruise on right arm when they moved in. LPA also reviewed photographic evidence of swollen feet, cracked nails, and a scab. Three out of five staff interviewed, corroborated that R1 had swollen feet and reported the incident. Per physician’s orders dated May 15, 2026, Amoxicillin 125mg oral tablets were prescribed for R1. Five out of seven residents, including R1 stated they had never sustained injuries due to lack of care. None of the evidence gathered supports the allegation.

Regarding the allegations that staff did not meet a resident’s bathing and incontinence needs, it was reported that showers are not being provided as agreed upon and resident was found in feces and soiled diapers. R1 requires assistance with bathing and toileting. Per records review, R1 showered at least once a week. Five out of seven residents interviewed, including R1, denied the allegation. Two residents interviewed could not provide any details regarding the allegation and responded with unrelated information. Four out of five staff interviewed denied the allegation. One out of five staff interviewed confirmed the allegation.

Based on the evidence gathered during the investigation, the allegations are found to be Unsubstantiated , meaning 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.

An exit interview was conducted, and a copy of the report was provided to a facility representative.