Complaint Investigation Report

they are checking on their residents every two (2) hours to change a resident if needed, to rotate a resident or if resident need assistance. Interviews with eight (8) of eight (8) staff indicated that there's no incident at the facility that they neglected R1, and they did not prevent R1 from developing pressure injury. Records review revealed that R1's on hospice care and receiving wound care. Interview with R1 hospice nurse on 05/22/2025 revealed that it was not due to staff neglect because R1 developed pressure injury but due to R1's change of condition and gradually decline in addition to R1 refusing care and severe agitation. Moreover, R1 hospice nurse stated that due to R1 declining health condition that started few weeks ago, they put R1 on comfort care medications.

The second allegation indicates that staff did not ensure resident’s room was free from odors. During the investigation, LPA Brown was not able to obtain sufficient evidence to corroborate the allegation. Four (4) of four (4) residents interviewed reported that staff at the facility clean their room every week and they stated that all staff at the facility ensure that their room was free from odors. LPA Brown unable to interview R1 as R1 unable to answer LPA Brown's questions. Interviews with nine (9) of nine (9) staff indicated that housekeeping staff are cleaning residents’ rooms once a week and care staff make sure that trash, food trays, leftover food are picked up daily to ensure that residents’ rooms are free from odors. Nine (9) of nine (9) staff interviewed said that there's no incident at the facility that they did not ensure that R1's room was free from odors. Records review showed that all housekeeping staff have a schedule to clean all residents’ rooms weekly. During the facility visit on 05/22/2025, LPA Brown observed that R1's room was clean and free from odors.

The third allegation indicates that staff did not ensure that a resident is using clean linen at all times. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with four (4) of four (4) residents indicated that all staff at the facility make sure that they always have clean linens. LPA Brown unable to interview R1 as R1 unable to answer LPA Brown's questions. Nine (9) of nine (9) staff reported that there's no incident at the facility that they did not ensure that their residents are using clean linens. Interviews with nine (9) of nine (9) staff revealed that they are changing their residents’ linens weekly and if they observed that a resident linen is dirty, they immediately change it. Nine (9) of nine (9) staff denied not ensuring that R1 always has clean linen. During the facility visit on 05/22/2025, LPA Brown observed R1 linens clean.

The fourth allegation indicates staff did not adequately assist resident with care needs. During the investigation, LPA Brown was not able to obtain sufficient evidence **Continuation in LIC9099C**