complaint·March 28, 2025

Interview with Witness #3 indicated that R1 did have a roommate but changing the resident was not a part of W3’s scope of work. W3 indicated that W3 was not present at the facility while R1 was changed. S1 indicated staff cover R1 by standing on the side of the bed to block him. The roommate is just looking at the TV. S1 indicated that the unknown adult could have been S1’s husband’s son in training but he left the room. On 03/28/25 around 1:30 PM, S1 clarified that the husband’s son was only visiting the facility and accidently went towards the room to say hello. S1 indicated that S1 immediately redirected the son because he was unaware that R1 was being changed. Interview with Staff #2 (S2) indicated the door is closed and the roommate watches TV while the resident is being changed. Two out of two resident interviews indicated they receive privacy during changes. LPA Cloyd did not observe a divider for shared bedrooms. Regarding the allegation "Resident was not accorded with privacy,” based on interviews, the preponderance of evidence has been met therefore the allegation is Substantiated. Deficiencies were issued. An exit interview was conducted and plans of correction developed. A copy of this report, and appeals rights was reviewed and left with the Administrator Antonia Dionisio. Record review of Physician’s Report revealed R1 was on a soft diet and the preplacement appraisal revealed R1 had a poor appetite, should not have salt or sugar, and needs assistance with eating. Record review of hospice plan of care revealed R1 can have one can of Boost daily as needed, small and frequent meals or snacks, thin liquids such as broths, juices, and water and high-calorie, nutrient-dense supplements if R1 is not consuming adequate nutrients from the mechanical soft diet. Three out of three (S1-S3) staff interviews indicated adequate meals and soft foods are provided. Interview with Staff #1 (S1) indicated R1 started with regular meals because R1 said R1 could eat it. The facility chopped regular meat and vegetables into tiny pieces and mash potatoes was always included. Then S1 indicated R1 had difficulty swallowing so R1’s meals were pureed. S1 indicated R1 could not eat much and would only take a couple of bites. Interview with Witness #3 (W3) indicated that R1’s nutrient-dense supplements were protein shakes. LPAs observed five vanilla Boost in a box, a pot of stringed chicken and rice (soup-like) and LPA Cloyd observed one resident eating oatmeal for breakfast. Two out of two resident interviews indicated adequate and balanced meals are provided. Witness #1 (W1) had no concerns about the food. W1 knew that R1 could not eat much and was aware that R1 needed soft food. W1 indicated that when W1 tried to feed R1, R1 would not eat it or would spit it out. W1 indicated that W1 had no complaints about the food. Regarding the allegation “Staff did not provided adequate meals for resident while in care," based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation: Regarding the allegation "Resident was not provided with activities,” it is being alleged that Resident #1 (R1) was confined to his room and not provided with any activities. Record review of Preplacement appraisal revealed R1 loves to read and watch sports. Needs and Services Plan reveals the plan is to keep R1 doing range of motion activities every day to promote good circulation. Hospice Plan of Care revealed regular positioning and mobility, even if limited to bed exercises, shall be promoted for gastro-intestinal purposes. Interview with Staff #1 (S1) indicated staff cannot give R1 any activities because R1 was in bed and was weak. S1 indicated they try to do some motion exercises but R1 would eventually stop. Continue to LIC9099-C. Interview with Witness #3 (W3) indicated there were no orders for recreational activities nor exercises because R1 was really weak. If you move R1 a little bit, R1 would be in pain. Witness #1 (W1) indicated that R1 really enjoyed being bathe. W1 indicated that R1 was too tired to do the stretch bands and R1 lost dexterity so R1 could not move much. W1 indicated that the nurses indicated that the stretches would probably do more harm. Regarding the allegation “Resident was not provided with activities," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Regarding the allegation "Staff did not address resident's change in condition,” it is being alleged that Resident #1 (R1) lost weight. Record review of Physician’s Report revealed R1 was 187 pounds as of 02/22/2025 and the status of R1’s physical health condition was poor. Staff #1 (S1) indicated R1 did not lose weight and if there is an issue, staff will call S1. Staff #2 (S2) indicated weight measurements were not taken. Witness #1 (W1) indicated that W1 could not tell if R1 lost weight, but the nurses were constantly at the facility. Interview with Witness #3 (W3) indicated W3 could not tell if R1 lost a lot of weight because R1 was only under hospice care for a few days. Prior to hospice care, the W1 and the doctor indicated that R1 lost a lot a weight. Regarding the allegation “Staff did not address resident's change in condition,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation: Regarding the allegation "Staff do not effectively communicate with resident's responsible party,” it is being alleged that staff does not answer the phones or when they answer, they hang up. It is also alleged that Resident #1 (R1) was not allowed to receive an incoming call. Continue to LIC9099-C. Staff #1 (S1) indicated that sometimes you cannot hear the caller well or the caller ID comes up as SPAM. S1 indicated they give Staff #2 (S2) the phone. S1 indicated R1 was able to speak with callers. LPA Cloyd observed a text thread between S1 and Witness #4 (W4) around 8:34 AM about having R1 return W4’s call after repositioning. Witness #1 (W1) indicated that W1 did not have issues talking to R1 on the phone. W1 indicated that W1 did not have issues with communication. Two out of two resident interviews indicated they are able to receive incoming calls. LPA Cloyd observed Staff #2 (S2) answer the phone, say hello, and then hang up. LPA Cloyd observed the landline ringing frequently and S2 answering each call. LPA Cloyd called the landline and was able to communicate with S2. Regarding the allegation “Staff do not effectively communicate with resident's responsible party," based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Regarding the allegation "Staff do not provide resident with assistance in a timely manner,” it is being alleged that staff did not assist Resident #1 (R1) when R1 needed help. It is alleged that R1 was uncomfortable and needed to be repositioned. R1 was in great pain in back and R1’s head needed to be adjusted. It is alleged that staff would answer R1’s call for help and that caregivers would just look in R1’s room and walk by. Record review of R1’s hospice Plan of Care revealed regular turning should be done. Plan of Care also encouraged repositioning every two hours. Record review of R1’s repositioning schedule revealed R1 was repositioned about 4-5 times per day. On 03/10/25, the day before R1’s death, R1 was repositioned eight times. Interview with Staff #1 (S1) and Staff #2 indicated that residents are assisted in a timely manner. S1 indicated that there was one occurrence in which staff could not reposition R1 because R1 was on the phone with Witness #4 (W4). S1 indicated that R1 was repositioned once R1 ended call. Two out of two resident interviews indicated that their needs are provided for in a timely manner. Witness #1 (W1) indicated that W1 did not have concerns or issues about the care being provided to R1. Continue to LIC9099-C. Regarding the allegation “Staff do not provide resident with assistance in a timely manner," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Administrator Antonia Dionisio.