Complaint Investigation Report

S2 never noticed any dirt or anything underneath R1s fingernails. R1 never scratched his/her butt. R1 never had any poo stains on him/her or bed sheets or on the clothes. S1 and S3 mentioned that the beddings are changed three times a week.

Additionally, LPA Maruffo interviewed four residents. R2 stated that staff assists a little bit. They assist with bathing. They may change the beddings when R2 is out in the kitchen eating. Usually, they clean R2s clothes every day or every two days. They bathe R2 every morning and R2brushes his/her own teeth. R3 shared that the staff showers him/her. R3 is showered two times per week. The staff help R3 brush his/her teeth. They change my diaper out. They change my diaper every other day. R4 mentioned that staff cleans his/her bedding. They clean R4s bedding every day. They throw out the old pads and put the new stuff in. R4 doesn’t know how often they clean the bedsheets. Staff cleans R4s clothes every day. R5 mentioned that someone comes in and does cleaning. Someone comes in at night and changes the bed sheets. R5 has never seen them (bedsheets) dirty or anything. Staff cleans R5s clothes whenever he/she needs it.

Regarding the allegation of staff are not turning the resident to prevent pressure wounds, RP stated that the physical therapist (PT) came out there after Memorial Day and told them they have to reposition R1 every couple hours and not once have they done it.

According to interviews, S1 stated that R1 is required to be turned in bed. S1 would turn R1 every two to three hours around the clock. That was the advice of the administrator. R1 did not have any bed sores. S2 also added that R1 required to be turned every 3 hours. Staff would turn R1 every 3 hours. S3 also shared that R1 is required to be turned. S3 always tell staff to turn the clients every two hours to avoid bed sores. R1 did not get any bed sores.

Based on records review, on the visit notes, visit done by PT on 5/23/2023, it was noted that R1 was confused and resistive, unable to get vital signs due to agitation. Educated caregiver for bed mobility.

Regarding the allegation of staff are not dressing the resident, RP stated that not once have they changed R1s top, R1 has been in the facility for 21 days.