complaint·May 9, 2023

It was then alleged that R1's needs were not being met. Resident #1 (R1) was admitted to the facility on October 30, 2020 and was discharged September 4, 2021. Upon admission, R1 was noted as non-ambulatory, having general weakness with chronic knee pain. Further, R1 was wheelchair bound, not being able to transfer themselves to and from bed, per R1’s Physician’s Report dated October 13, 2020. Further upon admission, R1 had Home Health services being provided by Suncrest Home Health for wound care. R1 was recognized to need transfers by staff with a two-person assist on R1’s appraisal document. R1 was noted to have contracted services to provide R1’s oxygen through Suncrest. It was alleged that staff ignores doctor's orders, has not kept up services for R1 such as Home Health and has allowed the R1’s oxygen certification to expire. The resident allegedly had not had oxygen for 3 months and due to not having oxygen (being a stand-alone unit that is incapable of traversing throughout the facility) had left R1 unable to leave their bed. At some point, R1 received a COVID-19 exposure, and was transferred to the skilled nursing side of Bayshire on January 20, 2021. On January 29, 2021, upon discharge from the skilled nursing, Bayshire requested a reappraisal and updated Physician’s Report. The new report showed that R1 was non-ambulatory but capable of independently transferring themselves to and from a bed. Progress notes indicated that per R1’s doctor, R1 was to have oxygen when placed in R1’s room, and staff to monitor. Interviews with outside sources indicated that R1 had a portable oxygen machine, as they regularly saw R1 in the dining area while R1 was utilizing the oxygen. Interviews with staff revealed that upon discharge from skilled nursing, R1 needed and received oxygen; however, staff interviews revealed that the facility did not develop a service plan to care for the oxygen and/or replace if/when necessary. Thus, the facility did not develop a plan to care for R1 and their oxygen needs. It was also alleged that R1 needed to have their ears flushed. There was not documentation provided by the facility to indicate that care was being provided. LPA was provided Suncrest Home Health documents by the facility dated February 11, 2021 through August 30, 2021. The documents indicated that Suncrest Home Health was providing weekly wound care to R1’s left knee and left great toe. It was alleged that on March 31, 2021, R1’s toe had gotten infected. A review of Suncrest notes on March 29, 2021 did not indicate that R1’s toe was, in fact, infected, but rather regular service to the wound. On April 1, 2021, Suncrest noted R1’s toe had shown no significant change. On August 30, 2021, notes indicated that R1’s toe was healing well. LPA reviewed records and found that on on March 3, 2021, staff were not providing R1 a physical assist per R1’s Resident Appraisal. A review of documents by Suncrest Home Health revealed that staff were not getting R1 up, and were later provided training to handle R1 by Suncrest Home Health. In conclusion, the facility did not provide or update a plan to care for R1’s needs. Thus, this allegation was found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811, LIC9099D, and Appeal Rights. It was alleged that Resident 1 (R1) did not receive their mail. Through interviews conducted with residents, LPA found that mail is kept at the reception desk, and that residents do not have issues receiving their mail. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed. It was alleged that staff are not adequately trained to transfer and meet resident's healthcare needs. Upon review of training submitted by staff dated June 1, 2021, documents revealed that staff had transfer training covering proper two-person physical transfers. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed. It was then alleged that R1's medications were not being managed. Upon review of the R1’s medication list and MAR, LPA discovered that R1 was being administered medications as ordered by R1’s physician. All five staff medical technicians who worked at the facility during the allegation no longer work there and were thus unable to be interviewed. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed. It was alleged that R1 was being charged for meals that were provided to R1 while in their room. Interviews revealed that the facility charges $10 for meals if a resident is not sick but wants a meal delivered to their room. The facility will not charge a $10 service fee if the resident who is requesting delivery is sick. Investigation revealed that; although R1 was charged $10 for meals, it was not clear as to what was communicated to staff as to the reasoning at the time of request. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed. It was alleged that staff does not ensure that R1's personal items were safeguarded. Regarding the alleged missing items, the missing items were allegedly delivered after R1 was admitted. Per R1’s resident appraisal, R1 was noted to have personal items ordered for R1, as well being provided by the facility. A specific count of what was used/not used was not available to be obtained to be reviewed to compare for discrepancies. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed. A finding of UNSUBSTANTIATED means 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 where a copy of this report was discussed with and provided.