Complaint·July 21, 2025

Allegation: Staff did not ensure that resident received medical treatment. Regarding the allegation “Staff did not ensure that resident received medical treatment,” it was alleged that facility staff failed to secure medical care for Resident #1 (R1) after R1 sustained a burn injury to his/her feet. To investigate the allegation, during the initial complaint visit on 04/14/2025, LPA conducted interviews with the Administrator, MedTech #2, two (2) staff members, and eight (8) residents. During the subsequent visit on 07/21/2025, additional interviews were conducted with the Former Administrator, MD, Primary Physician, and MedTech #1. Interview with the Administrator revealed that on 03/07/2025, R1 spilled boiling water on his/her feet and staff offered medical assistance and hospital transport; however, R1 refused. LPA reviewed the Special Incident Report (SIR) and did not observe documentation of any 9-1-1 call or outside medical transport. Interviews with MedTech #1 confirmed the burn incident and that no 9-1-1 call was made. MedTech #1 stated R1 refused medical treatment and hospital transport. The MD confirmed that no formal outside medical assessment was arranged and documentation of refusal of care was incomplete. The Primary Physician informed LPA that he advised staff to transport R1 to the hospital for evaluation; however, the facility did not follow this recommendation. Interview with R1 at 12:15 PM confirmed the incident occurred; however, R1 stated he/she declined hospital transport. R1 further indicated receiving informal treatment with cream and home remedies but no outside medical evaluation. During the interview with R1, LPA observed the burnt present on R1’s feet and not being healed or covered. Based on interviews and record review, the facility failed to ensure appropriate medical follow-up after the burn injury and did not document refusal of care per policy. The facility also failed to follow the physician’s recommendation for outside medical evaluation. Therefore, the allegation is Substantiated. Allegation: Staff do not ensure that client's mental health needs are met. Regarding the allegation “Staff do not ensure that client’s mental health needs are met,” it was alleged that R1’s psychiatric and mental health needs were not addressed. To investigate the allegation, during the initial visit on 04/14/2025, LPA conducted record review and interviews with the Administrator, two (2) staff members, MedTech #2, and eight (8) residents. During the subsequent visit on 07/21/2025, additional interviews were conducted with the Former Administrator, the Associate Director of the Department of Health Services, and MedTech #1. Interview with the Administrator revealed that psychiatric appointments are scheduled but that R1 frequently refuses to attend. However, documentation of scheduled appointments and refusal forms was not provided. Record review did not reveal evidence of appointment scheduling or care plan updates addressing mental health services. Interview with the Former Administrator confirmed awareness of psychiatric services but stated that responsibility for scheduling appointments had been transferred to the Department of Health Services social worker. Continue on LIC 9099C The Associate Director of the Department of Health Services clarified that the facility remains responsible for arranging psychiatric services and transportation, though the department assists with coordination. No documentation of appointment scheduling was provided. Interviews with MedTech #1 indicated that R1 often refuses services but no formal documentation of refusals were made such as reappraisal and or incident reports. Moreover, LPA reviewed all incident reports on a system and did not observe an incident report regarding psychiatric appointment refusals. Based on interviews and documentation review, the facility failed to demonstrate efforts to arrange or document psychiatric services for R1. The lack of evidence supporting mental health follow-up supports the allegation. Therefore, the allegation is Substantiated. Allegation: Staff did not keep the facility free of cockroaches Regarding the allegation that staff did not keep the facility free of cockroaches, it was alleged that the facility had an infestation of cockroaches and bedbugs. To investigate the allegation, during the initial visit on 04/14/2025 at approximately 10:30 AM , LPA toured the facility and observed the general condition of the physical plant. Interviews were conducted with the Administrator, two (2) staff members, MedTech #2, and eight (8) residents . During a subsequent visit on 07/21/2025 , additional interviews were conducted with the former Administrator, MD, and MedTech #1 . During interviews, the Administrator, staff, MedTechs, and MD confirmed that the facility had experienced issues with cockroaches and bedbugs . MD reported that the facility is contracted with a pest control vendor, Ecolab , which is currently providing facility-wide pest control treatments to address the pest issues. Additionally, one (1) out of eight (8) residents interviewed reported witnessing bedbugs in their bedroom and cockroaches in the facility’s main elevator . Although LPA did not observe cockroaches or bedbugs during the facility tours, based on staff confirmations and the resident statement, there is sufficient evidence that pests were present in the facility . Therefore, the allegation is Substantiated . Deficiencies issued and appeal rights explained and given. Exit interview conducted and copy of this report signed and delivered.