complaint·July 16, 2024

Regarding the allegation “Staff do not provide proper transportation assistance to resident's medical appointments” it was alleged R1 has been late to and left at dialysis appointments. Interview with R1 revealed they had switched health insurance providers which limited their transportation options. R1 required transportation to and from dialysis appointments which were scheduled between 12:00 p.m. to approximately 3:00 p.m. When the facility transported R1 to their dialysis, there were “three (03) to four (04) times” when R1 was “stranded” there until 4:00 p.m. or 4:30 p.m. Interview with the former ED at 11:30 a.m. on 12/21/23 revealed the facility could not exactly fit R1’s schedule due to other residents who required transportation. In total, the facility missed one (01) of R1’s appointment’s. The previous ED spoke with R1’s dialysis agency to coordinate future visits. Interview with Staff #1 (S1) at 12:00 p.m. on 12/21/23 revealed the facility pick up and drop off times “may not match” R1’s appointment times. Interview with Staff #3 (S3) at 12:30 p.m. on 12/21/23 revealed the facility shuttle would leave around 11:30 a.m. to get to R1’s noon appointment, and one (01) time, R1 was left waiting for a while. The facility shuttle went there right away when staff had found out. Interview with Staff #8 (S8) at 1:00 p.m. on 12/21/23 revealed they would drive R1 to their dialysis appointments and wait with R1 if they arrived early. At times, R1 would say they were ready, but S8 had to wait approximately to thirty (30) minutes for R1’s blood to clot. S8 stated there was one (01) occasion when R1 had to wait to be picked up due to other residents requiring transportation. Based on interviews, the facility did not provide proper transportation to at least one (01) of R1’s dialysis appointments. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is cited on the corresponding LIC 9099-D page. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided. Regarding the allegation “Staff did not report incident to resident's responsible party” it was alleged the facility did not report an assault on R1 by another resident. Interview with R1 revealed they were shoved by their roommate around October of 2023 after an argument. R1 fell and bled, but no major injuries were sustained. Interview with Staff #1 (S1) at 3:00 p.m. on 03/06/24 revealed they observed the incident and reported it to their supervisor, Staff #2 (S2). Interview with S2 at 12:00 p.m. on 12/21/23 revealed they reported the incident to R1’s responsible party, physician, and Community Care Licensing on 10/28/23. LPA was unable to contact R1’s responsible party to confirm the report had been received. Record review revealed the incident was reported along with an abuse report. The reports detailed R1 required minor medical care. Both had fax receipts attached. Based on interviews and record review, the facility reported the incident to R1’s responsible party and other necessary parties. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not clean resident's room” it was alleged bloody sheets were left in R1’s room for five (05) days. Interview with R1 revealed they had bled on their sheets from the incident with their roommate, and staff left the sheets in a corner of the room. Interview with the previous ED, S1, S2, Staff #3 (S3) at 12:30 p.m. on 12/21/23, Staff #4 (S4) at 12:45 p.m. today, Staff #5 (S5) at 1:10 p.m. today, Staff #6 (S6) at 11:00 a.m. today, and Staff #7 (S7) at 3:15 p.m. today revealed no staff saw or remembered bloody sheets in R1’s room. S5 noted they provided care for R1 almost every day for extensive periods of time. R1 never mentioned bloody sheets to S5 nor did S5 observe dirty sheets in R1’s room. S4 noted they always cleaned R1’s room to their liking. Based on interviews, the facility sufficiently cleaned R1’s room. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not keep resident's room free of odors” it was alleged the facility did not address the odor in R1’s room. Interview with R1 revealed a rat had been stuck in a trap in their room which caused a strong odor. Interviews with seven (07) out of seven (07) staff revealed they did not detect an odor in R1’s room. S4 and S5 noted they never noticed a rat trap in the room. Based on interviews, the facility maintained R1’s room free of odors. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not provide adequate food service to resident” it was alleged the facility did not provide dinner to R1 after they returned late from dialysis appointments and missed the scheduled dinner times. During the facility tour at 10:00 a.m., today LPA observed the facility meal times posted near the dining rooms. A sign showed Breakfast 7:30 a.m. – 9:00 a.m., Lunch 11:30 p.m. – 1:00 p.m., and Dinner 4:00 p.m. – 5:30 p.m. Interview with R1 revealed they usually returned around 4:30 p.m. and missed dinner. R1 was offered a sandwich or a burger, “but nothing good”. Interviews with the previous ED, Staff #9 (S9) at 9:45 a.m. today, and Staff #10 (S10) at 10:00 a.m. today revealed the facility always has sandwiches and snacks available to residents, and the kitchen staff can save dinner for a resident when they are notified. Interviews with three (03) other staff also revealed that R1 had not missed any meals. Based on interviews and observations, the facility provided adequate food service to R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.