complaint·March 1, 2023

(a) Continued from LIC9099. two (2) hours during the day and every three (3) hours in the early morning. Based on the investigation the above allegations are substantiated. Resident became severely dehydrated in facility . Reporting Party (RP) reported Resident became severely dehydrated in facility. Based on record review of facility’s incident report Resident 2 (R2) was transported to the hospital on 12/25/2019 and discharged on 12/29/2019. Discharge summary report from the hospital did not indicate that R2 was dehydrated, but R2 did have an unspecified infection pending lab results. Staff did not administer resident’s medications per physician’s order . RP stated that R1 was prescribed medication and the facility stopped administering the medication which sent R1 back to the hospital. Based on record review and interview the medication for resident was discontinued on 5/05/2020. S2 stated during interview that staff faxed R1’s doctor on 5/23/2020 to confirm medication had stopped because R1 had been in and out of the hospital and there were a lot of changes. S2 also stated that R1 was given two (2) prescriptions for same medication and both were stopped. Staff did not obtain timely medical care for resident RP reported the doctor had requested R1 to return to the hospital after R1 had called the doctor and the facility resisted to call 9-1-1 until two (2) to three (3) hours later. During record review LPA observed facility's incident report dated 5/10/2020 at 7:30PM, indicated R1 was assessed by staff and staff contacted advice nurse. Continued on LIC9099C (b). (b) Continued from LIC9099C. Advice nurse stated the doctor requested R1 to be admitted and 9-1-1 was called. Although time may have elapsed before the facility called 9-1-1, the facility had to follow protocol, therefore the facility did obtain medical treatment in a timely manner. Facility charged resident for services that were not provided RP stated that facility was charging R1 and R2 an escorting fee during facility’s COVID lockdown, and R1 an dressing assistance fee even though he was not getting dressed. During interview with S1 it was stated that the facility did continue the escorting and dressing assistance charges. S1 stated the facility staff continued getting the residents dressed during the lockdown unless the resident refused. S1 also stated even though the residents were isolated in the room the escorting fee was still being charged to the residents that had previously been receiving escort services, but none of the residents were being charged tray service to their rooms. During record review LPA observed a memo dated 3/13/2020 which stated the facility strongly encourage residents to opt for complimentary room service due to dining room restrictions. LPA also observed that R1 and R2 had completed escorting assistance three times daily before lockdown, and that the facility was in a sustained COVID surge from April 2020 until November 2020. Staff failed to properly maintain resident's room. RP stated the hired private caregiver stated that on the first day of employment R2’s room was dark, on a Spanish channel and the cat’s care needed attention. There were no other days mentioned about the room or the cat. Based on record review of Continued on LIC9099C (c). (c) Continued from LIC9099C. R2, individual service plan dated 1/16/2020, R2 was receiving pet assistance care twice a day and daily bed making. Staff did not provide proper care for resident. RP stated that R2 was bathed or had a sponge bath once in a while, and her teeth not cleaned every day. Record review indicated that R2 was receiving AM and PM grooming assistance, and bathing assistance one (1) day a week. Review of summary of services provided by facility explains services, how many days, how much time, and the price of the service. S1 stated the additional personal services are agreed upon after the resident have been admitted into the facility and an individual service plan have been completed. S1 stated that sometimes the individual service plan must be revisited and updated but the new plan is discussed with the residents’ responsible party, and if a residents’ responsible party request more days or times to a service a new individual service plan is created and signed . Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of this report provided.