complaint·May 18, 2025

(continued from LIC 9099) Regarding the allegation that Staff did not ensure resident’s room was adequately cleaned, it was alleged that R1's room had urine multiple urine stains. LPA's interview with two (2) Memory Care staff today who were here when R1 was still at the facility revealed that they regularly do a light cleaning on everyone's room and the housekeeper do general cleaning of everyone's room once a week. LPA's interview with housekeeping staff yesterday 05/17/25, revealed that they shampoo R1's room whenever requested by the former Resident Service Director (RSD) but denied that it had urine stains. LPA's interview with six (6) Assisted Living (AL) residents revealed six (6) out of six (6) residents state that their room are being cleaned regularly by staff and do general cleaning once a week. Regarding the allegation that Staff did not assist resident with personal hygiene care, it was alleged that staff did not make sure that R1's hands were clean and did not file R1's nails and staff also did not wash R1's face or help brush R1's teeth. LPA's interview with two (2) Memory Care staff today who were here when R1 was still at the facility revealed that during their shift (AM) they regularly assist R1 getting up to bed, clean, brush teeth, shower during schedule days and dress and groom before breakfast every day. They stated however that cutting and filing nails were not part of their duty as it may hurt R1 so they had to bring R1 to a podiatrist or a salon. Further, when R1 was admitted to Hospice care, the hospice staff were doing R1's bathing and grooming, including but not limited to nail trimming and filing, shaving, etc., LPA’s record review of hospice notes confirmed that the hospice staff were assisting on R1's ADLs. Regarding the allegation that Staff did not dispense resident’s medication as prescribed, it was alleged that R1 was being over medicated because staff were dispensing medications as directed by an old doctor’s order and not the newest order. LPA's record review revealed that since R1 started on Hospice services, it was the hospice staff checking and reconciling R1's medication and due to R1's condition medication orders changed faster than usual. Further review revealed that all the medications administered to R1 from the period August 2024 up to the time of R1's passing on October 2024 were given as prescribed. (continued on LIC 9099-C-2) (continued from LIC 9099-C) Regarding the allegation that Staff did not refill resident's medication in a timely manner, it was alleged that R1 ran out of heart medication but staff did not inform RP until one week later. LPA's record review revealed that R1 was using facility non-contracted pharmacy, in which the family member and/or responsible party are the ones responsible for contacting the pharmacy for refills. Further review also revealed that R1 did not miss any regularly prescribed medication from July 2024 until the time of R1's passing on October 2024. Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.