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32 | The investigation revealed the following:
Allegation: Resident sustained pressure injury while in care due to staff neglect
It is alleged that R1 has a pressure injury to their left foot heel due to improper care at the facility. LPA reviewed R1’s file and found that R1 was observed to have redness to their right foot on 5/6/26 and on 5/21/26 R1’s physician prescribed heal protectors with instructions for staff to notify physician if the pressure ulcer opens, the pressure ulcer was not staged in the documents provided by physician. Per staff there were no indications of there pressure ulcer getting worse but they were documenting their observations and monitoring it. LPA interviewed 10 Residents and each denied sustaining any pressure injuries and stated they don’t feel staff would neglect a situation like this.
Allegation: Staff did not provide resident medical attention in a timely manner
It is alleged that R1’s sugar level is high due to the lack of care at the facility. LPA interviewed 5 Staff and each denied the allegation and stated that residents in assisted living that require sugar monitoring are only assisted with the process and must be able to self administer the needle to get their sugar reading or have Nurse come do it for them. S1 and S5 explained that R1’s son would take responsibility for this as R1 has a device on their arm that will alert R1’s son on an app when sugar levels drop or rise and R1’s son is to notify the facility when this occurs. LPA interviewed R1’s son and they confirmed that they help with the device and monitor it on their phone. LPA interviewed 10 Residents and 9 out of 10 residents denied the allegation, with residents stating they get medical attention in a timely manner, R2 and R8 stated they have experienced injuries where they have to call for help, staff arrived immediately and sent them to the hospital right away.
Allegation: Staff did not assist resident with bathing needs
It is alleged that R1’s clothing smells and is believed that this is because R1 is not receiving their 2x weekly bath/shower. LPA obtained copies of shower log during initial visit on 6/19/26, there were missing log’s for 5/22/26-6/1/26 and during todays subsequent visit Executive Director could not show proof of the logs. LPA interviewed 5 Staff and each denied the allegation stating that R1 was refusing showers. Interviews with S1 and S5 revealed that R1 had been refusing showers, LPA revisited shower logs provided and observed that on 5/21/26, 6/2/26, 6/9/26, 6/11/26 R1 had refused showers which was documented in the logs. LPA interviewed 10 Residents and 8 out of 10 residents denied the allegation and stated they are assisted as needed with showers.
Based on statements and interviews conducted with staff, review of staff files & facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, a copy of this report was provided. |