Complaint Investigation Report

The review of R1’s service plan states that R1 has full dentures but refuses to wear the dentures.

4 staff members were interviewed. Based on staff interview, 4 out of 4 staff did not remember R1 using dentures. It was stated that R1 moved from Assisted Living to Memory Care and staff did not remember R1 moved into memory care with dentures.

Based on record review of R1’s safeguard of personal property and valuable form, there were no items to include the dentures that was entrusted to the facility. The word “waived” is written across the form and the form was signed and dated by R1’s responsible party on 03/17/2021.

It was alleged that the facility staff did not ensure that R1’s hygiene needs were met while in care as it was observed that R1 was filthy after not being bathed for a week. It was alleged that R1’s hygiene needs were not met because the facility was short staffed. The date of this encounter is unknown.

Based on record review, R1’s showers were scheduled twice a week and required staff hands on assistance.

4 staff members were interviewed. Based on staff interview, 4 out of 4 staff denied R1’s hygiene needs being neglected by the staff. Staff states that R1’s family did not bring up any concerns that R1 wasn’t showered for a week. Staff states the facility was short staffed around July 2023 but denied the shortage of staff reflecting on the shower schedule. Staff states the residents were still being provided their showers on their scheduled days. The review of the facility’s staffing schedule shows that there were at least 3 staff scheduled in memory care, in the AM and PM.

It was alleged that staff did not ensure R1 had clean linens while in care as there was a day where R1’s responsible party and R1’s social worker needed to change R1’s bedsheets because they were soiled. Page 2 of 3.