complaint·March 28, 2022

Regarding the allegation that facility staff left resident in soiled clothing for extended periods of time, the Investigation revealed that (1) of (2) staff in question stated they did not leave any residents in soiled clothing for extended periods of time. LPA was unable to contact additional staff member due to invalid phone number provided. No additional number is listed for former staff member. LPA visited facility a couple of times and during these visits Residents clothing was neat in appearance, LPA did not observe any soiled clothing. Upon reviewing documentation's, it was revealed that nearly over 50 pages of medical notes revealed that R1’s skin was intact. Nursing Summary Reports also stated that “patient has no skin breakdown, care plan is effective.” Medical notes revealed that on 3 separate dates in October 2020 that Resident (R1) had redness in buttocks area and ointment was applied with improvement and skin intact no edema noted. RN interviewed stated no major skin issues such as rashes. It was alleged that Facility staff are not dispensing medication as prescribed and facility staff do not keep accurate medication logs. The investigation revealed that designated staff, were in charge of medication dispensed to residents at facility. During R1’s time at facility Staff 1 (S1) was designated to dispensing meds to R1. Staff Member 3 (S3) is currently dispensing medications to residents as indicated in interview from 6/16/2021. Documentation provided revealed facility maintained centrally stored medications and destruction records. LPA observed on several visits that medications reviewed at facility showed residents receiving monthly meds prescribed as per Medical Log signed by S3. Medication notes for R1 indicated medication was handled by facility and hospice staff. Medication notes indicated that “patient and or family/caregivers have been determined to be safely administering medications/biologicals” and that “caregiver is proficient with medication administration”. Staff 1 and 2 are no longer working at facility to confirm distribution. Staff 1 and 2 were main caregivers during R1’s time at facility. Interview with S1 when asked about allegation S1 stated they kept logs. LPA was unable to interview S2. Although medication logs provided by Facility appeared to be in compliance, logs reviewed via witnesses appear to show medications were not being given as prescribed. It remains inconclusive which logs reflect the accurate distribution of R1’s medications. Regarding allegation facility staff did not communicate with residents authorized representative, investigation revealed that 4 out of 5 staff members and 1 of 2 residents interviewed confirmed that Licensee kept in contact with residents’ families. Resident 2 (R2) indicated that Licensee was in contact with their family on a daily basis. Staff indicated that if residents have issues and inform staff, staff will then inform Administrator in which Administrator addresses representatives. CONTINUED ON LIC 9099C Regarding facility staff did not ensure that resident was dressed appropriately for the weather, based off interviews conducted 3 of 5 staff claim they assisted and dressed residents accordingly in light clothing for hotter weather and covered up in sweaters for cold weather. Resident 2 who was interviewed stated they require some assistance and are dressed accordingly for the weather as well. Investigation also revealed that 5 out of 5 staff claimed they don’t speak inappropriately around or towards residents. Same 5 out of 5 staff stated they have never heard any other staff speak inappropriately. S1 admits to speaking sternly and claimed they would raise their voice to residents for example when trying to get a resident to eat or take medication, claiming, “it was out of concern for their own good”. S1 is no longer working at facility. Based on the information gathered during the investigation, interviews and review of documents obtained the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, these allegations are deemed UNSUBSTANTIATED. This report was reviewed with Administrator and a copy left at facility along with confidential names list