complaint·December 14, 2023

followed-up on September 19, 2023 requesting R1’s full file including MARs, incident reports, etc. The POA received an email from the Director of Nursing on September 27, 2023, stating that they were working on compiling the file. According to the previous Administrator Jessica Sanders, all records requests are processed through the corporate office. The previous Administrator acknowledged that another resident’s information was accidentally provided to the POA of R1. Additionally, according to the timeline of emails and the interview with the previous Administrator, the facility provided R1’s requested facility records approximately 4 weeks after the initial request. Furthermore, once the requested documents were provided, there were documents for 5 other residents documents (R2-6) provided to the POA. Allegation: Staff did not properly dispose of trash The previous Administrator Jessica Sanders stated that R1’s POA was upset that once there was an instance of used incontinence products left in R1’s bathroom. Staff interviewed stated that R1’s room was normally kept tidy and clean. Interviews stated that the facility has dedicated housekeeping which deep cleans each room once per week. Care staff are responsible for cleaning accidents which may occur during the week. LPA also interviewed R1’s hospice nurse who stated that they would visit the facility twice per week. Per this hospice nurse, there were often where used incontinence products were discarded in the room or bathroom, rather than being taken to the trash. LPA was provided photos which show used incontinence products in R1’s room, outside of the trash can on several occasions. Allegation: Staff are not following medication orders. According to the reporting party, R1 was prescribed Lorazepam 1 mg every four hours as needed. The reporting party was told by a med tech that they were giving R1 this medication every four hours routinely. LPA reviewed R1’s scheduled and routine medications. According to the controlled substance count sheet, R1 began taking this medication in October of 2022 as PRN. LPA reviewed PRN MARs from May – September 2023. LPA also reviewed the facility’s controlled substance count sheet for this medication. According to the controlled substance count sheet, this medication was given as needed until 8/24/2023. On 8/24/2023 until 8/28/2023, R1 was given this medication at 7am each morning. According to R1’s hospice nurse, they spoke with staff and instructed them to give this medication as needed, and not routinely. LPA also identified that the MAR and controlled substance count sheet did not match. Staff were not correctly signing the MAR as this medication was given. Allegation: Staff are not meeting residents' needs According to the interview with R1’s POA, R1’s incontinence needs were not met. The POA provided documentation which showed that several times they found R1’s bed soaked with linen. Additionally, interviews with staff stated they did the best they could, but R1’s incontinence needs were not always met timely. Additionally, staff interviews acknowledged that R1 would often have dirty clothes as they would spill food on themselves during mealtimes. Allegation: Staff did not notify resident’s authorized representatives of incidents During R1’s stay at the facility, they had had approximately six witnessed falls and 12 unwitnessed falls documented in observation notes. According to both the POA and hospice nurse, POA was not notified of every fall. Observation notes state that on 8/7/2023, R1 was found on the floor by care staff. Hospice was notified. POA arrived at the building after hospice notified them of the incident. Additionally, LPA’s interview with R1’s hospice nurse revealed that R1 had a fall on 9/1/2023. Again, R1’s POA was not notified of this fall until they received a call from the hospice nurse. Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. and dinner meal was served with a vegetable. Care and kitchen staff stated that fresh fruit and vegetables are served daily. Furthermore, staff stated that there is always extra food available should a resident want additional servings. Allegation: Staff are not meeting resident's laundry needs LPA interviewed care staff on all shifts in regards to R1 and their laundry needs. Staff interviewed stated that R1 required frequent clothing changes after meals. Additionally, R1 required incontinent care which sometimes led to a change of clothes. Staff stated that R1 always had dirty clothes to be laundered by the facility. However, staff interviewed also stated that R1 was never without clean clothes. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. A copy of this report was emailed to the Administrator.