complaint·September 5, 2023

has dispensed and that the resident has received medication as prescribed by the physician. According to training received by facility staff; When staff arrive for their shift, the staff is to review the MAR sheet, and both the arriving and departing staff should sign off acknowledging that the MAR sheets are accurate. However, LPA found that there were several times where staff reported signing upon arrival for their shift and the departing staff had already signed, noting a discrepancy and a false claim. Therefore, the allegation Staff are falsifying facility's records is SUBSTANTIATED. Medications are not given as prescribed. The allegation noted above was investigated by the Department; Facility documentation were reviewed, and interviews were conducted; the following was revealed; Upon reviewing Resident #4 (R4) file, prescription notates that R4 can have Baclofen three times a day as needed. However, on the Medication Administration Records (MAR) sheet, documents that R4 can only have the medication once a day. R4 also had a prescription for an antibiotic that was written on January 2, 2021, and as of January 6, 2021, R4 had not received the prescribed medication. Staff explanation was that they were too busy to fill the prescription; the staff’s employment was subsequently terminated soon after this information was revealed. As a result, the facility staff failed to dispense medications as prescribed by physician. The allegation of medications are not given as prescribed is SUBSTANTIATED. Resident(s) toileting needs not met-Left sitting/laying soiled clothing. LPA reviewed pertinent documents and conducted interviews with staff that indicated that they were not comfortable with things that were happening at the facility such as the overnight staff allegedly sleeping for the most of their shift. Such as sleeping instead of checking on resident’s is a contributing factor of the residents not being changed. Per feedback provided from staff interviews; Staff were reporting for their shift, the call button would be going off, would conduct their initial checks and would find as many as three residents completely soiled in their urine or feces or both. Therefore, the allegation of Residents toileting needs not met-Left sitting/laying soiled clothing Is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Neglect/Lack of Care and supervision: Facility staff failed to provide resident #1 with timely medical care. The allegation noted above was investigation by the Department; facility documentation was reviewed, and interviews were conducted. The following was revealed; On September 22, 2020, it is noted in Resident #1 (R1) log, that R1 was noted to be hardly breathing, white foam coming out of the resident’s mouth, unable to swallow, gagging and appeared to be choking. Staff #1 (S1) stated that hospice had been called in an effort to assist the resident during this incident. With R1 being a hospice patient, it is the expectation for hospice to be notified first in case of an emergency and or change of condition. However, the hospice agency denies that they were ever contacted for this incident. Although, Hospice had come to the facility on the same date as the mentioned incident; this was for regularly scheduled visit and not for a change of condition, as stated by the facility staff. Per the hospice documentation reviewed dated September 22, 2020, the Nurse was at the facility from 8:45am-10:45am, care was provided to R1 (lotion, massage, bed bath, grooming, dressing). There was nothing documented supporting/referring to a change in R1s condition. R1 was described as very agitated and restless at the time of the hospice visit. The facility staff # 1(S1) failed to seek medical treatment for the resident in a timely manner. As a result, the allegation facility staff failed to provide R1 with timely medical care is 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 and copy of this report, 9099D and appeal rights were provided to Lora Statler, House Manager It was determined that the facility administered the medication accurately. During an interview conducted with the RN Executive Director from the hospice agency, stated that because “the amount of levels prescribed of both the morphine and Fentanyl would not cause for someone to overdose. If there were to be an overdose of the medications it would not cause foaming at the mouth but a highly sedated state.” Therefore, the allegation of Questionable Death is UNSUBSTANTIATED. Staff chemically restrained resident in care. The allegation noted above was investigation by the Department; Facility documentation were reviewed, and interviews were conducted; the following was revealed; LPA reviewed medication related documents, such as Hospice agency prescription/dosage log along with the facility Medication Authorization Record (MAR) as well as the PRN (as needed) logs. R1 was prescribed Morphine (1ml/1h PRN), Temazepam 15 mg at night, repeat 1 every hour if it is ineffective, and Fentanyl (50mcg every 72 hours). It was determined that the facility administered the medication accurately. After record review Medication was given according to the prescription label. Therefore, the allegation of Staff chemically restrained resident in care is UNSUBSTANTIATED. Staff handled resident in a rough manner, causing bruising. The allegation noted above was investigation by the Department; Facility documentation were reviewed, and interviews were conducted; the following was revealed, LPA reviewed pertinent documents, such as photos that show that Resident #3 R3 did have multiple bruising going down their arm ending at just above the ending of resident’s, index and middle fingers bruising however the bruising was unexplained. Administrator Christopher states that the staff did not report the bruising and had not been made aware until LPA inquired. There was nothing notated in resident’s log for the months of October and November 2020 regarding the bruising. Per resident’s Physician report dated 01/05/18, R3 was not considered to be a fall risk. Administrator Chris did state that prior to R3’s death R3 was a moderate fall risk. It was reported that there was a staff that allegedly caused the bruising and was fired as a result. However, per the Licensee, Mushtaq Khan denied that the reason for terminating the staff’s employment had anything to do with the staff handling R3 in a rough manner, it was for an unrelated matter. Therefore, the allegation of Staff handled resident in a rough manner, causing bruising is UNSUBSTANTIATED. Residents not being assisted with bathing needs. LPA reviewed pertinent documents such as hospice notes and resident observation logs, and conducted interviews with staff revealed that staff denied not assisting any residents with their bathing needs. Resident #1 (R1) is noted to have bathing from both the home health aide as well as the facility staff. Based on interviews and record review the allegation of residents note being assisted with bathing needs is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report was provided to Lora Statler, House Manager.