Complaint Investigation Report

They explained that R1 first lived in Assisted Living (AL) and later moved to Memory Care as health and behavior changed. Staff said R1 sometimes refused care and liked things done a certain way, which made helping R1 more difficult. Staff also said R1 sometimes tried to stand up on their own even though R1 was no longer able to walk safely. At night, R1 sometimes refused to get out of bed to use the bathroom, so staff cleaned R1 in bed. Staff also said R1 had a long history of UTIs, even when R1 lived in AL and was more independent. Staff confirmed that R1 was not assessed to have one-on-one care but did receive help during meals because R1 ate slowly.

Staff said they checked on residents often and followed care plans for bathing, dressing, toileting, and other ADLs. Residents with mobility problems were kept in common areas where staff could watch them more easily.

Record reviews showed that after R1 broke their collarbone, staff followed the doctor’s orders and helped R1 with all ADLs while keeping R1’s arm in a sling. R1’s care plan was updated eight times between July 2021 and February 2024 due to falls, UTIs, and changes in condition. Progress notes from 7/2/21 to 7/25/24 showed entries where R1 refused care and entries showing staff checked on R1 often and responded to their needs. Service plans from 2021–2024 showed that R1 went from being mostly independent to needing much more help by late 2023. Physician’s Reports from 2021 and 2024 also showed a clear decline in mobility, diet needs, continence, and cognitive abilities. There was no indication that R1 needed one-on-one care. Records also showed that staff received training in several areas, including fall incidents, memory care rounds, reporting procedures, hydration, proper storage of personal items in memory care, environmental safety, dementia care, hygiene, wellness checks, and daily care routines .Residents interviewed during the investigation said staff helped them with bathing, hygiene, and other needs. They did not report problems with call-button response times. A family member visiting the MC unit also said they had no concerns about staffing, care, or food. During LPA observations on 7/2/25, 7/18/25, and 12/29/25, staff were seen helping residents with meals and feeding those who needed assistance.

Based on interviews, record reviews, and observations, there was not enough evidence to show that staff did not assist residents with their care needs in a timely manner. Although R1 sometimes refused care and R1’s condition declined over time, the information gathered shows that staff followed the care plan and responded to her needs. Therefore, this allegation is unsubstantiated.