Complaint Investigation Report

Regarding the first allegation, "Lack of supervision led to resident sustaining a fall". Direct observation by LPA as well as outside source records and interviews, showed that the facility staff had systems in place to monitor ambulatory residents, and that residents are allowed to walk around the facility, including within the perimeter gate, without line-of-sight supervision. There was no evidence of injuries for the resident in question, and additional eyewitness interviews revealed that the resident may not have actually fallen but had possibly been participating in another activity that was not related to falling, such as exercising or resting on the ground. Interviews with numerous outside service providers revealed that the caregivers were timely in their attention to each resident, including when ambulatory residents were in the outside patio area. There is no evidence to support that any resident went outside of the perimeter fence and off the facility property alone. On two unannounced facility visits Department staff directly observed the supervision of all residents by facility staff. During these visits all residents were tended to within reasonable amounts of time, and staff interviews revealed that the facility has systems in place to ensure resident supervision needs are being met, such as performing regular resident checks and utilizing the back-up caregiving staff who live on the property to assist when necessary.

Regarding the second allegation, "Facility staff did not meet resident's hygiene needs", direct LPA observations, record review, attempted interview, and outside source interviews showed that all resident hygiene needs were reasonably tended to. On two unannounced facility visits Department staff directly observed residents in care, finding all residents to be dressed in clothing free from debris, food particles, and/or stains. Staff interviews and facility documents revealed that residents are on a twice per week shower or sponge bath schedule, according to the needs outlined in their care plans. At times residents will express their personal right not to be showered, reducing the number of showers they receive each week. Service provider interviews indicated that all resident’s hygiene needs were monitored and maintained within appropriate levels based on their care plan. There is no evidence that show any resident being neglected regarding personal hygiene care.