However, staff revealed that R1 has episodes of agitation, removes their depends and yells at staff that they want to be alone, this behavior was confirmed during records review of hospice notes obtained on 8/2/21. LPAs obtained daily care notes for the month of June 2021. However, the information was very limited in details to prove or disprove the above allegation. LPA will issue a Technical Advisory to the facility for staff to include more details into the daily care notes log. A finding that the complaint allegation facility staff did not provide adequate incontinence care is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation of Staff are not assisting resident with grooming needs. During this investigation LPA made observation, conducted interviews and reviewed records. Reporting party provided information that grooming needs for R1 were unkept, R1’s hair was observed not been cared for. Based on confidential interviews conducted with staff on 6/24/21 and 7/19/21 indicated that staff are assisting R1’s with their grooming needs on Mondays and Wednesdays with a sponge bath. Tuesdays, Thursdays and Friday hospice nurse performs a full bath. LPAs observed a paper on R1’s room confirming this information. However, facility does not keep a record in their daily care notes. Based on records review of (R1) Physician report dated 12/30/2019 with a diagnose of Dementia and blank LIC625 dated 2/28/20 that revealed that Resident (R1) has not been assessed for an updated care plan as stated on facility’s Dementia Care Plan. LPA conducted confidential interviews with staff and Licensee it was confirmed that R1 has not been assessed per CCL regulation within the last 12 months. LPA will address facility not following their Dementia Care plan dated 4/19/2019 on a case management inspection. During LPAs visits to the facility conducted on 6/25/21 and 7/19/21 residents appeared to be well groomed and dressed appropriately. Based on records review of daily hospice notes obtained on 8/2/21 confirmed that R1 initiated receiving hospice care since 5/27/21 until the present twice per week. R1 was found on 6/1/21 “R1 without a diaper, their bed and R1 was very wet. R1 had just jeans and was covered from the waist to the chest just a thin blanket, their room and hair are very dirty”. On 6/2/21 “R1 was very confused, repeatedly said that wanted to be left alone, House manager and hospice nurse agreed to try premedicating R1 with Lorazepam 0.5mg before personal care from now on. R1 was found without diaper, wet bed, no shirt on”.

Continues on LIC9099C...

Facility is not clean and sanitary

During the investigation LPA/staff toured, made observations at the facility and conducted interviews on 6/24/21 and 7/19/21. During the tour of the physical plant the bathrooms and resident’s rooms appeared clean, free of odors and sanitary. Confidential interviews conducted with other residents (R2, R3 and R4) no concerns were raised and residents were satisfied with care and supervision provided by the facility. Based on records review of hospice notes it was determined that R1 initiated receiving hospice services since 5/27/21 to the present and on 6/1/21 R1’s room was found dirty. Also, LPA’s interviews and observations, LPA has determined and confirmed that although the facility including bedrooms and bathrooms were clean and in a sanitary condition on recent LPA inspections conducted on 6/24/21 and 7/19/21, LPA is unable to determine if an area of the facility was unclean or unsanitary condition at a prior date.

A finding that the complaint allegation facility is not clean and sanitary is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.