complaint·April 14, 2023

CONTINUED FROM FORM LIC9099 A follow-up visit was conducted on this day, during which the Maintenance Director was interviewed and Medication Administration Records were reviewed. Regarding the allegation that Staff do not maintain a comfortable temperature for residents in care, the following has been concluded: After a similar allegation was made as part of complaint 22-AS-20221228101134 filed on December 28, 2022, temperature measurements were taken during multiple facility visits on January 4, January 17 and February 3, 2023 as well as during today's visit. Facility received a citation in regard to the faulty heating units. Based on following observations and interviews conducted, there was not sufficient evidence to confirm that the issue was still ongoing. As a result, the allegation is Unsubstantiated, meaning that 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. Regarding the allegation that Staff did not ensure that resident was provided their medication in a timely manner, the following has been concluded: LPA observed MedTech staff while touring the facility and reviewed print-outs of the Medication Administration Records for the months of March and April for a random sample of five residents out of 20 currently present within the facility. All daily doses are observed to have been administered correctly and typed into the system adequately. The allegation is therefore deemed to be Unsubstantiated, meaning that 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. Regarding the allegation that Staff do not ensure that residents are provided with activities while in care, the following has been concluded: During the initial visit, facility staff was observed wrapping up activities as listed and residents resting. Further interviews with the facility's Activities Director confirmed that activities were being offered to residents on each weekdays when Director is present, but that was not generally the case on weekends due to the responsible staff member not being scheduled on those days and care staff not having the availability to pitch in significantly. Administrator states that more dedicated staff may be hired if and when facility census gets higher. Therefore, the allegation is found to be Unsubstantiated, meaning that 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. An exit interview was conducted and a copy of this report was reviewed and left to facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff are not sufficiently trained, the following has been concluded: Based on a review of a random sample of staff records reviewed during the initial investigation visit on February 3, 2023, all applicable training was found to have been adequately received and documented. A limited number of shifts are covered by Registry staff with potentially less knowledge of the facility's residents, however the placement agency is also responsible for ensuring that their provided staff have received the required training. Therefore, the allegation is found to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was reviewed and left to facility representative. CONTINUED FROM FORM LIC9099-A LPA additionally reviewed two Special Incident Reports submitted by the facility to the Department on March 17, 2023 and March 21, 2023 regarding two fall incidents that occurred during the use of the recliner seats with the legs in the upward position. A follow-up visit was conducted on this day, during which the Maintenance Director was interviewed and Medication Administration Records were reviewed. Regarding the allegation that Staff are restraining residents while in care, the following has been concluded: Based on interviews conducted and observations made during three separate tours of the physical plant, recliners were confirmed to have been in use in the upward position during each of the visits. Even though residents did not appear to exhibit signs of distress at the time, the Department later received two incident reports linked to fall incidents that occurred while the recliners were up and residents with limited mobility or impaired cognition were not able to exit the seats safely without staff assistance. As a result, the allegation that Staff are restraining residents while in care is deemed to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B citation is issued regarding the deficiency substantiated during the investigation. An exit interview was conducted and a copy of this report along with appeal rights were reviewed and left at the facility.