Regarding allegation, “Facility staff did not reposition resident in timely manner” – Information was provided that staff would not reposition residents’ as required (date/time unknown). Staff interviewed denied the allegation and reported that R1 was repositioned at least every 2 hours. Staff documentation/notes revealed that R1 should be repositioned daily at least every 2 hours through-out the day. R1’s responsible person interviewed expressed no concern with service provided by facility staff. According to R1’s responsible person R1 was assisted with all daily activities as needed. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Facility staff did not reposition resident in timely manner” is deemed UNSUBSTANTIATED at this time.

Regarding allegation, “Facility staff do not meet resident's toileting needs” - Information was provided that on or around 02/09/2024, R1’s diaper was not changed all day and R1 was red from wearing the same diaper all day. Staff interviewed denied the allegation and reported that R1 was assisted with all toileting needs; checked and changed daily at least every 2 hours or as needed.

Continued on LIC 9099-C

Interview conducted with R1’s responsible person revealed that staff assisted with all activities of daily living which included but not limited to toileting needs. According to R1’s responsible person, R1 and other potential witnesses interviewed, care services provided by facility staff were good and there was no concern of any unmet needs including but not limited to R1’s toileting needs. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Facility staff do not meet resident's toileting needs” is deemed UNSUBSTANTIATED at this time.

Regarding allegation, “Facility staff do not ensure toiletries are available for restroom use” - Information was provided that restrooms did not have soap or paper towels. During the initial visit on 02/29/2024 facility restrooms observed with adequate supply of soap and paper towels. Staff interviews revealed that they facility maintains adequately supply of toiletries including but not limited to soap, toilet paper, hand sanitizer and paper towels. LPA Conway conducted a walk-thru of premises and observed an ample supply of paper towels, toilet paper, soap, hand sanitizer, shampoo and extra hygiene products. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Facility staff do not ensure toiletries are available for restroom use” is deemed UNSUBSTANTIATED at this time.

Regarding allegation, “Facility staff are not assisting resident with their mobility brace” – Information was provided that R1 previously came from a skilled nursing facility where R1 utilized braces for hands and legs due to body contractions. It was reported that R1 was required to wear the braces for 4 hours a day total. Staff interviewed denied the allegation and reported that there was no order for R1 to utilize a mobility brace. Facility records pertaining to R1 reviewed did not reveal any standing order for the use of mobility brace. Interview conducted with the hospice nurse confirmed that R1 was not required to wear any mobility brace at this facility.

Continued on LIC 9099-C

R1’s responsible person interviewed expressed no concern with service provided by facility staff. According to R1’s responsible person R1 was assisted with all daily activities as needed. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Facility staff are not assisting resident with their mobility brace” is deemed UNSUBSTANTIATED at this time.

Regarding allegations, “Facility staff do not meet resident's dietary needs and Facility staff do not provide adequate food service to residents” - Information was provided that there was no meal plan for the residents who required a purée diet, it was also reported that residents were provided meals from the family and not the facility and that often the residents were left hungry. During the initial and collateral visit LPA Conway observed ample supply of non-perishable food and a refrigerator filled with but limited to fresh vegetables, meats and dairy products for residents in care. Staff interviewed denied allegations stating staff cook three (3) meals a day and provides snacks to residents in care. Furthermore, staff stated that R1 had an puree order on file and staff were follow doctor’s order. According to staff puree diet was offered daily. Resident’s interviews conducted revealed that they are satisfied with the food portions and variety of options the facility is providing. Additionally, interviews with R1’s responsible person expressed no concern with the food provided to R1 and confirmed puree diet was provided. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Facility staff do not meet resident's dietary needs” and “Facility staff do not meet resident's dietary needs and Facility staff do not provide adequate food service to residents” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted, and a copy of this report and appeal rights were provided.