Complaint Investigation Report

Facility did not meet resident’s hygiene needs

In June 2021, resident (R1) was brought to a nail salon where it was found R1 had multiple hard dark matter and yellow gunk underneath the fingernails.

Based on observation of the photograph provided from R1’s visit to the nail salon in June 2021, the photograph showed the yellow and black gunk/hard matter that was removed from underneath R1’s fingernails.

Based on record review, R1’s services plan dated April 19, 2021 states the service of bathing/showering seven times per week and grooming two times a day. R1’s physician report states the need of assistance in bathing and toileting.

The facility did not ensure to meet R1’s hygiene needs despite the service of daily bathing/showering from the observation of the build-up of yellow and black gunk underneath R1’s fingernails.

Facility did not communicate properly with family member

In January 2021, the facility had a COVID-19 outbreak resulting in multiple residents and staff contracting COVID-19. R1 was part of the group of residents who contracted COVID-19 and recovered.

During a care conference in August 2021, R1’s responsible person(s) was informed R1 had not received the COVID-19 vaccination after recovery from COVID-19 in January 2021. Based on record review, R1’s records did not state the responsible person(s) was notified or received a follow-up that R1 had not yet received the COVID-19 vaccine after recovery.

Resident’s room not large enough to allow for easy passage and comfortable usage of bed and other furniture

In January 2021, R1 was relocated to a shared room in memory care. R1 used a wheelchair and hospital bed.