complaint·January 30, 2024

It was alleged staff did not meet the needs of an incontinent resident. It was reported to the Department residents were found with soiled incontinence briefs. Interviews with internal and external sources did not reveal any concerns regarding staff not providing incontinence care. Interviews did reveal some of the residents may have experienced an increase in bowel movements and this may have contributed to staff encountering residents with soiled briefs, but there were no concerns with lack of care. Additionally, there were no concerns with skin irritation, nor breakage due to lack of incontinence care. It was alleged staff did not assist residents with prescribed medication and that staff falsified documents. It was reported to the Department facility staff had witnessed medications had been dispensed, documented as taken by resident, but instead placed in a medication cart. Interviews with internal sources did not recall witnessing any similar incidents, nor the staff not assisting residents with medication. External sources did not have any concerns with lack of medication assistance. The facility did not produce the records requested by the Department, as they were not readily available. It was alleged Staff were not following a resident's care plan. It was reported to the Department staff had not assisted residents with showers. Interviews with internal and external sources did not corroborate staff were not assisting residents with showers, nor did they reveal any concerns with lack of assistance from staff. Interviews did reveal that during the time period in question, there were staff disagreements that had led to staff blaming each other. Records requested from the facility were not readily available for review. It was alleged staff did not ensure hazardous items were inaccessible to residents. It was reported to the Department that a Salon in the Memory Care unit was not secured; therefore, chemicals and sharp items were accessible to residents. An interview with the Executive Director at the revealed the facility had addressed the concern about the door not locking properly. Interviews with internal and external sources did not corroborate chemicals, nor sharp items being accessible to residents. During a visit to the facility, the LPA witnessed the salon to be locked and used for Personal Protective Equipment storage. Additionally, the Reporting Party disclosed having photographs corroborating the door was unlocked. These photographs were not provided to the Department. (See additional LIC 9099-C for continuation of report.) It was alleged staff did not maintain a comfortable temperature for residents. It was reported to the Department staff left residents windows open at night. Interviews with internal and external sources did not reveal any concerns regarding staff leaving residents windows open. Staff would close windows at the residents’ requests. Additional interviews revealed residents had reported rooms may have been warm and management addressed this with the facility maintenance personnel. There was no evidence to corroborate windows were left open, nor that this resulted in residents having cold like symptoms. It was alleged facility staff failed to follow reporting requirements. It was reported to the Department facility staff did not follow the facility's internal process of reporting concerns. External sources revealed some staff would report concerns to management team and would expect management to follow up with them when follow up was not required, or necessary.. Interviews with internal and external sources, including third party providers, did not reveal any concerns with lack of communication from staff. Based on the evidenced obtained throughout the investigation, there was not a preponderance of evidenced to prove the alleged violations occurred, therefore, the allegations were unsubstantiated. An exit interview was conducted with Michael Sokoloswky, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.