Complaint·October 13, 2022

LPA Soto requested the following documents: Pre-placement Appraisal, Physician’s Report, Admissions Agreement, Emergency Contact Info, Appraisal Needs and Services Plan, Home Health Agency Notes, Daily Log/Caregiver Notes, Menus for January 2020 – March 2020, Incident Reports, Medication Administration Records for October 2020, November 2020, and December 2020, Staff Training Records, and Mandated Reporter form (SOC 341). On 08/29/22, LPA requested the following records: Resident and Staff rosters, and Menu for August 2022. LPA observed residents as LPA was interviewing them & took pictures of the food being served for lunch. Toured room #1 & #2, living room, dining room, and kitchen. A separate investigation was conducted by Department of Social Service Investigator (Lorraine Patterson) which included review of Cedar Sanai Hospital medical records (dated 12/14/20), Home Health Agency (HHA) medical records (dated 12/15/20), and interview with facility staff and medical services staff. Allegation #1 : Staff did not seek medical attention in a timely manner. IB investigator’ investigation revealed Resident #1 had bouts of agitation; and struggled to accept support with activities of daily living which may have been a contributing factor. Resident #1 was medically assessed on 09/11/20 with an infected toe. Medical records obtained revealed Resident #1 was seen by her Primary Care Physician (Dr. Allison Moser Mays) on 12/14/20. A physician’s order referral was made by the primary care physician for plan of care with home health agency – certification period to begin effective 12/15/20 – 02/21/21. HHA Skilled Nurse to perform wound care protocol to toe injury and Stage 2 pressure ulcer of sacral region. HHA Skilled Nurse to instruct resident/caregiver to report measures of preventing and treating constipation. Primary Care Physician also ordered a physical therapy plan of care for Resident #1. While, allegation may have occurred or were valid, there is a lack of preponderance of evidence to corroborate that the facility failed to seek out timely medical attention, therefore the alleged is found UNSUBSTANTIATED. Allegation #2 : Physician stated that the condition of the resident was severe. IB’s investigation revealed the primary care physician reported that Resident 1’s toe injury was not “time related” to her “virtual” medical assessment on 12/14/20 and/or her “bed sore” as reported by the Home Health Agency to Resident #1’s family member on 12/15/20. As a mandated reporter, the primary care physician reported to adult protective services as to what was told to her by the resident’s family member; however, Resident #1’s family member filed the suspected elderly abuse report (via APS). Primary Care Physician further reported no evidence for and/or against neglect. When the paramedics went out to the facility on 12/11/20 to assess Resident #1, the outcome suggested by the paramedics was to have Resident #1 follow up with her primary care physician. It was further reported that it is difficult to say ongoing neglect occurred - based on what was observed during the intake assessment. It was too difficult to complete the assessment due to Resident #1 not cooperating, would refuse to be assessed and was agitated. It was also observed that one could not touch Resident #1 without her screaming and hitting the person. While, allegation may have occurred or were valid, there is a lack of preponderance of evidence to corroborate if Physician stated that the condition of the resident was severe, therefore the alleged is found UNSUBSTANTIATED. Allegation #3 : Residents are not getting their needs met. LPA’s investigation revealed the facilities documented Resident #1’s blood pressure and glucose level (via Tracker) during the month of December 2020. A review of Resident #1’s records (Pre-placement Appraisal, Physician’s Report, Admissions Agreement, Emergency Contact Info, Appraisal Needs and Services Plan, Home Health Agency Notes, Daily Log/Caregiver Notes, Incident Reports, Medication Administration Records for October 2020, November 2020, and December 2020) were observed to be current. Facility instituted a daily log for resident in care and facility staff have documented notes (dated 12/01/20 – 12/16/20 regarding Resident #1. Resident #1 was provided with ongoing sponge baths, applying ointment on bedsore, cleaning of private area, combing hair, cutting nails, changing adult diapers, bed pads, and clothes; meal service, taking vitals, and administer/manage medications. Interview with R#1, was not available to be interviewed. R#2 – R#5, stated that the facility helps with all their ADL’s, such as: Sponge bath and/or showers, changing clothes, put on shoes, hair care, personal hygiene (change diapers) walking, and transferring from bed to wheelchairs. Licensee and Staff stated that they always help all residents with the ADL’s and hygiene needs. The interviews and records review did not concur with the above allegation. Allegation #4: Staff are not reporting incidents to responsible party. Interview with S#1, was adamant that all S#1’s staff report all incidents that happen at the facility and in turn S#1 will notify Family or RP if it’s necessary. The facility will report any incidents such as; injuries, miss medication, etc. depending on the nature of incident. S#2 & S#3, all agreed that they always report everything that happens at the facility to S#1. Interviews with R#2 – R#5, haven’t had incidents that required for family or Responsible Party to be notified. R#1 could not be interviewed due to R#1 mental disability. The interviews did not concur with the above allegation. Allegation #5: Food service inadequate. Interviews with S#1 – S#3, all agree that the facility offers a well-balanced meal. All 3 meals are very nutritious and very appetizing. Interviews with R#2 – R#5, all agreed that the meals are always good They all like the food and it tastes good. LPA reviewed the menus for January 2020 – March 2020, and August 2022, the menus are well-balanced and have all the four foods groups. LPA took pictures of lunch being prepared for resident and it had vegetables and protein. They were also serving fruit and juice/milk along with the vegetables and protein. The food smelled good as it was being cooked. The interviews and observations did not concur with the above allegation. Allegation #6: Staff are unable to communicate with the residents. Interview with S#1, denies not being available to communicate with her residents. S#1 has a British accent, but S#1 can communicate well with all the residents. S#2 & S#3, both stated that they speak English and can communicate very well with the residents. LPA spoke with S#1 - S#3, in English and was understood by all the staff. LPA understood all the staff also. LPA and staff did not have any problems communicated or understanding each other in any way. LPA completed the staff interviews without any need of a translator. The interviews and observations did not concur with the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated An exit interview was conducted with Naome Leibov, Office Manager, and a hard copy of report was provided.