Complaint Investigation Report

During interview, five of five staff stated residents are provided with bathing assistance based on their individual care plan and preferences, and clean linen is provided at least once a week and as needed for each resident. During interview, R1’s responsible party, Witness 1 (W1) stated R1 routinely receives assistance with bathing. Per W1, R1’s clothing and linen is washed by staff once a week and a supply of clean linen is available in R1’s bedroom.

Regarding allegations, Staff do not ensure resident is kept in clean clothing at all times and Resident developed pressure injuries while in care, the following was revealed: Complaint alleges staff did not ensure R1 was kept in clean clothing and R1 developed pressure injuries. During the course of the investigation, interviews were conducted with R1, three staff, and one witness. During interview, R1 was unable to confirm or deny allegations. During interview, Staff 1 (S1) stated they provide direct assistance to R1 with activities of daily living. Per S1, R1 does not usually request to be changed, however, S1 will change R1’s clothing if they observe it to be soiled. S1 denied R1 having any pressure injuries. During interview, facility nurses, Staff 2 (S2) and Staff 3 (S3) denied ever witnessing R1 in soiled clothing and denied R1 developing any pressure injuries while in care. During interview, R1’s responsible party, W1 denied ever witnessing R1’s bedding or clothing to be soiled. W1 stated R1 had acquired a sore prior to being admitted to the facility and stated the sore was treated by a facility nurse. W1 was unable to identify facility nurse who treated R1’s sore and stated they had no knowledge of any other pressure injuries.

Regarding allegations, Staff do not ensure resident's room is kept free of mal odors and Staff do not ensure resident's room is kept in clean and sanitary conditions, the following was revealed: Complaint alleges staff did not ensure R1 room was kept free of mal odors and in clean and sanitary conditions. During the course of the investigation, interviews were conducted with five facility residents, five staff, and one witness. During interview, R1 was unable to confirm or deny allegations. Three of five residents interviewed stated their room is in clean and sanitary condition and denied having any housekeeping concerns. One of five residents interviewed was unable to confirm or deny allegations. During interview, five of five staff stated all facility areas, including R1’s room, are kept free of mal odors and are in clean and sanitary conditions. During interview, R1’s responsible party, W1 stated they visit the facility every Sunday to see R1 and stated they had no concerns pertaining to mal orders or the cleanliness of the facility. (Cont. LIC9099-C)