complaint·March 23, 2022

their food with no one present to witness or assist. Therefore, the allegation that residents are not properly supervised is SUBSTANTIATED. Regarding the allegation that staff do not administer medications to residents as prescribed by physician, on 2/18/2022 LPA Tryon visited the facility to work on the complaint. While there, LPA met with Angelica Rothhaupt, Wellness Director. Ms. Rothhaupt and LPA did a medication review of 4 of 20 residents. In reviewing medications present, MARS and daily computer Medication Logs, it was found that there were two PRN (as needed) medications for resident R4 that were noted on medication orders, but the medications were not present in the medication supply. Therefore, if the resident had ever needed those 2 medications, the facility did not have them available to give to R4 as prescribed. The allegation is SUBSTANTIATED. A finding that an allegation is substantiated means that the allegation is valid because a preponderance of the evidence standard has been met. The following deficiencies are cited as per Title 22 Regulations. Appeal rights were provided, exit interview conducted. Regarding the allegation that residents sustained injuried while in care, Department Staff reviewed facility records, medical records, interviewed staff and witnesses. It was learned that resident R3 did have an unwitnessed fall. Staff said that R3 was alone for approximately a half hour. R3 was sent to the ER. Medical records reported a closed displaced intertrochanteric fracture of left femur, oth er closed intra-articular fracture of distal end of left radius. R3 underwent hip surgery and a left write closed reduction. The responsible party for R3 reported no concerns for the care received at the facility. Department Staff interviewed R3, but R3 was unable to answer any questions. In interviewing staff, it was learned that R3 was not initially considered a fall risk and could independently move around. Physician report dated 5/4/2020 indicated R3 was able to independently transfer to and from bed and was ambulatory. Since R3’s fall, the Physician Report has been updated and R3 was noted to be a fall risk, and a sensor added to R3’s room. Allegation is UNSUBSTANTIATED. Regarding the allegation that Staff uses drugs at the facility, the Department has interviewed staff. Staff denied witnessing other staff using drugs at the facility. It was learned that there were suspicions that certain staff were under the influence of drugs or had a smell that was thought to possibly be the smell of marijuana; or smelled “like a skunk.” It was found that the staff who allegedly “smelled like a skunk” never returned to work at the facility after the allegations were made. In speaking with the previous Executive Director, it was learned that there were concerns and allegations that another staff person was “under the influence” but the staff stated she was “tired.” That staff person was changed from a Medication Technician positive to a caregiver position. That staff never returned to work after questioned. Another staff interviewed said that “a lot of staff” thought another staff person was on drugs. However, it was never confirmed that any staff were ever actually under the influence of drugs while working. Therefore, the allegation is UNSUBSTANTIATED. A finding that an allegation is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Regarding the allegation that the facility does not meet residents’ nutritional needs, LPA has viewed several meals at the facility, reviewed documentation, spoken with several residents and spoken with staff. There were no complaints regarding the food or nutrition, staff related that the food appears to be of good quality and nutrition, and portions are good. LPA observed the food to look appetizing and varied, and a good portion. The allegation is UNFOUNDED. Regarding the allegation that staff handles residents in a rough manner, LPA has toured the facility, met with several residents, spoken with 12 of 22 staff, and reviewed documentation. Residents related that staff has not been rough. Although a few staff said they have seen other staff appear to be frustrated and speak sternly with a resident occasionally, no staff interviewed had ever personally seen any other staff treat a resident roughly; and no bruises such as fingerprints were ever documented. There was an incident reported last year when a new staff claimed to have seen another staff be rough while transferring a resident, but the situation was investigated, and no marks or bruises were found. Staff involved left employment after the allegation. Therefore, there is no evidence to support the allegation. Allegation is UNFOUNDED. Regarding the allegation that facility does not maintain a disaster plan, LPA has reviewed facility documents, and found that the facility does in fact have a disaster plan present in the facility Therefore, the allegation is Unfounded. Regarding the allegation that the facility is malodorous, LPA has visited the facility on 9/24/2021, 10/11/2021, 12/15/2021, 12/20/2021, 2/18/2021 and 3/10/2021. LPA has walked through the facility on each occasion. During these visits, the LPA noted no offensive odors of any sort at any place in the building. LPA cannot speak for times in the past, but the facility appeared to be odor free during visits since September 2021. Therefore, the allegation is Unfounded. Regarding the allegation that the facility is not maintained clean and sanitary at all times, LPA has visited the facility on 9/24/2021, 10/11/2021, 12/15/2021, 12/20/2021, 2/18/2021 and 3/10/2021. LPA has walked through the facility on each occasion. During these visits, the LPA noted the facility appeared to be clean, and free of odors. LPA cannot speak for times in the past, but the facility appeared clean and sanitary during visits since September 2021. Therefore, the allegation is Unfounded. Regarding the allegation that the facility is not maintained in good repair, LPA has visited the facility on 9/24/2021, 10/11/2021, 12/15/2021, 12/20/2021, 2/18/2021 and 3/10/2021. LPA has walked through the facility on each occasion. During these visits, the LPA noted everything appeared to be in good repair. LPA did learn that the elevator to the second floor was having issues at some time in 2021, but the facility made an effort to have it repaired as quickly as possible. There were reportedly some technical issues, but it was repaired. LPA learned of no other issues. Therefore, the allegation is Unfounded.