Complaint Investigation Report

On 04/12/2024, LPA conducted an initial facility site visit for a complaint investigation into the allegations above. LPA interviewed residents, staff, and conducted record review of relevant documentation to the allegations. According to staff interviewed by LPA, on 03/28/2024, R1 had asked staff to get blankets because they were in cold water for a while. Staff interviewed by LPA stated they couldn’t tell how long R1 was in the shower. The staff stated to LPA that R1 was not unconscious or slumped over, but just was in cold water for a brief period. Staff interviewed by LPA stated that R1 should not have been in that shower location because it’s supposed to be closed as the drain clogs. The administrator of the facility stated R1 wasn’t supposed to be in that location, and that R1 has been told not to use that shower before, because it’s broken. The administrator additionally said R1 was taking a shower and dropped the washcloth. Staff stated to LPA that after the shower incident R1 was in their room with numerous blankets on, shivering. Staff interviewed by LPA stated that R1 had been in the shower, freezing cold, trying to warm up. Staff stated to LPA that R1 should never have ambulated from their room to the shower, with no walker present.

LPA requested and received relevant facility documentation pertinent to the allegation. Through record review, the Physician’s Report for R1 dated 01/30/2024 states that R1 has the capacity for self-care including bathing and dressing/grooming. R1 has a secondary diagnosis of unspecified visual loss as well as a history of falls documented in the Physician’s Report. The mental condition of R1 is listed as confused/disoriented, but R1 has no documented wandering, aggressive, sundowning, or inappropriate behavior according to the Physician’s Report. Additionally, R1 has a documented physical health status of motor impairment/paralysis with an unsteady gate and refusal to use a walker. The Resident Appraisal of R1 dated 02/03/2024 states that R1 can care for themselves physically with the ability to understand and communicate their needs. The 02/03/2024 Resident Appraisal of R1 does state that R1 has had a decline in mental condition and cognitive changes. R1 is also documented to need required grab bars in the bathroom for safety but does not need help with bathing. However, the Resident Appraisal states that R1 does need help setting up a new environment when bathing. The 03/09/2024 Needs and Services Plan for R1 indicates that R1 has independent bathing during the morning (AM) everyday Monday-Friday. R1 is listed as able to shower on their own. Staff do need to set up the shower to ensure safety in a new environment. Staff will monitor R1’s hygiene for changes and staff should notify the home health agency representative if R1 requires assistance. R1 moved into the facility on 02/04/2024 due to anticipated decline related to a diagnosis of cancer and hospice needs. The Assisted Living Advantage Resident Assessment for R1 dated 01/25/2024 states that R1 bathes independently and showers on their own without reminders, stand-by assistance from staff, or total assistance from staff. Continued on 9099-C