Complaint Investigation Report

Regarding the allegation that staff are not following the resident’s toileting care plan. More specifically, the concern involved whether Resident #1 (R1) was receiving regular toileting and incontinence care. Department record review revealed hospice and nursing documentation showed that R1 received full assistance with toileting, wore incontinence briefs, and received bowel care interventions as needed. They further revealed coordination between hospice and facility staff regarding bowel movements, constipation management, and hygiene needs. Department interviews with internal and external sources support staff consistently assisting with toileting care needs for residence.

Regarding the allegation that staff do not provide resident adequate food service or assistance.

More specifically, the concern related to whether R1 was being fed appropriately and consistently. Department record review revealed hospice staff and facility staff frequently documented R1’s meal intake. Outside Source records review and interviews with facility staff reveal that facility caregivers were assisting with feeding, offering supplements, and reporting changes in appetite throughout hospice decline.

Regarding the allegation that staff do not keep the resident’s room clean, sanitary and free from odor.

More specifically, it was alleged that R1’s room was unclean or malodorous. Department observations and record review revealed no documented concerns from outside visiting clinicians regarding odors or sanitation, and department observations during the many inspections showed the room was clean and odor free.

Regarding the allegation that staff do not ensure the resident has clean laundry. More specifically, the concern involved whether R1 had regular access to clean clothing and linens. Records and outside source interviews revealed that outside visiting sources consistently observed R1 to be clean, groomed, and appropriately dressed, with no concerns documented regarding laundry or linens. Department interviews with external sources support staff consistently assisting with laundry as well as cleaning of the individual residents rooms.

Based on interviews, direct LPA observations, and records review, interviews with internal and external sources a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Topete, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.