Complaint Investigation Report

Documents obtained from facility show in July and the beginning of August 2023 there was 27 residents on the East side of the building & 18 residents on the West side, 35 one person assists & approximately 9-10 (2) person assists, 2 use Hoyer lifts and 1 is on oxygen. (I2 -Co complainant) reported being requested to lift and carry a resident so that the staff could assist in dressing them and managing the residents catheter bag. During tour of facility on 8/9/2023 at approximately 1:45pm, LPA and S1 observed on east side hallway R2 went to the bathroom on the floor in other residents’ room and in the hallway floor. R2 had also wiped fecal matter on other residents’ door (see pictures). There was fecal matter on resident’s pants, hands, and shoes. There was no care staff in sight. While opening another complaint at facility on 8/25/2023 at approximately 10:40am with LPA Coppo, LPA’s toured both sides of facility and observed on the west side dining/kitchenette 4 residents and 2 residents in the courtyard - LPA's did not observe any staff. On the east side of the (locked) facility, walking the entire unit, LPA's did not observe any staff on this side either, other than a Med Tech leaving the med room for break. As LPA's were leaving the unit a caregiver R4 walked up and stated they were in a resident room with another staff changing a 2 person assist resident. Based on interviews, observations, & record review, LPA was able to obtain a preponderance of evidenc e that facility has insufficient staffing to meet the needs of all the residence.

Complaint also alleges facility is not able to supply appropriate incontinent care products, the families pay for the facility to have incontinence products and the facility is out of them. On 6/27/2023 LPA conducted inspection of facility and was informed by R3 the depends being used are cheap, do not fit & are scratching them. On 7/21/2023 LPA received call from Individual ( I4) who was at the facility and observed resident wearing incontinent products that do not fit and are leaving marks on resident after requesting many times for briefs that fit. On 8/9/2023 LPA was informed by S1 the incontinence company that delivers the product stopped for approximately a month at the end of June /beginning of July. They were saying there was a due bill that was not paid, although the facility never received this bill. S1 went to the store and bought them two different times. (receipt’s for 6/29/2023 - briefs for residents - men & women) and again on 7/16/2023). LPA contacted Incontinence supplier on 9/18/23 who informed the facility was placed on a hold in March 2023 due to lack of payment, in April with a verbal agreement they began shipping again. Although facility attempted to provide incontinence products for the residents when the company that provides this product for the facility stopped due to lack of payment, the product did not appropriately fit. Based on interviews, observations, & record review, LPA was able to obtain a preponderance of evidence that facility is not able to supply appropriate incontinent care products during reported time of allegations. The allegation is Substantiated .