complaint·April 24, 2024

Review of medical and assessment records dated 2019 revealed that Resident 1 (R1) had a diagnosis of mild cognitive impairment, was confused and disoriented, was able to follow directions and communicate with staff, and required 1 person assistance with bathing, grooming, dressing, and transfers, and required standby assistance for toileting care, and required wheelchair escorting to meals and activities. Interviews with staff and outside sources revealed that R1 was hospitalized and transferred to a higher level of care sometime in late 2019 to early 2020. After R1 returned to the facility, R1’s care needs had increased and R1 had a diagnosis of major cognitive impairment and required 2 person assistance and additional time for toileting, bathing, and transfers, as confirmed by interviews with staff and outside sources and review of medical and assessment records dated 2020. Review of R1’s medical records dated 2020 revealed that R1 was receiving physical therapy services for weakness in their lower extremities and difficulty with ambulation. Additionally, R1’s needs and service plan dated 2020 revealed that staff were instructed to provide bathing and incontinence care in bed during the evening and overnight if R1 felt too weak to be transferred out of bed for care. Interviews with staff and outside sources confirmed that R1 was provided with incontinence and bathing care while in bed after R1 returned from the higher level of care. Interviews with staff and outside sources revealed that R1 used incontinence briefs and was not able to consistently communicate their needs following hospitalization, and staff would check on R1 multiple times a day and respond to call lights for incontinence care. Interviews with staff and outside sources provided conflicting information regarding if R1’s incontinence needs were being met overnight but confirmed that staff would respond to call lights and check R1 for soiled briefs during the night. Interviews with staff and outside sources revealed that staff would assist R1 with transferring by lifting R1 with the use of a gait belt and while holding onto R1’s arms. Interviews with staff denied any bruising or injuries from transferring. Interviews with outside sources provided conflicting information regarding bruising on R1’s arms and stated that R1 may have sustained bruising due to a fall in the shower. Outside sources stated during interviews that there were instances where staff were not available to transfer R1 and outside sources would assist R1 with transferring. Interviews with outside sources and staff revealed that R1 received medication management from facility staff. Interviews with staff revealed that R1’s spouse was an active participant in R1’s care and would frequently speak with R1’s physician to change R1’s medication orders, resulting in medications being discontinued without facility staff notice. Continued on LIC9099-C page... Interviews with staff confirmed that medications for R1 had been changed or discontinued by R1’s spouse without a written notice provided to the facility, and staff would explain to R1’s spouse that the facility needed an updated written order to administer medication differently. Review of communications between the facility and R1’s physician in 2020 confirmed multiple communications where medication orders were requested to be changed due to a request by R1’s family. Additionally, those communications and interviews with staff and outside sources revealed that R1’s spouse would occasionally refuse to allow staff to administer medications to R1 due to requested changes in how the medication was prescribed or if R1’s spouse believe the medication was not given at the exact time. Interviews did not reveal any specific descriptions of medications that were administered incorrectly or missed for R1. Review of pest control records in 2020 revealed that the facility had an ongoing contract with a pest control company who provided pest control services to the facility on a monthly basis. Review of those records revealed that due to the COVID-19 pandemic, services were only provided on the exterior of the building, but pest control staff would verify any concerns with facility staff prior to services being provided. The pest control company provided bait and extermination services for rodents and insects and provided the facility with best practices to prevent insects or rodents. Interviews with staff and outside sources revealed that when the facility first opened in 2019, there was an issue with insects, however, those interviews did not provide the Department with the severity of the insect issue or which portions of the facility were impacted. Interviews with staff revealed that due to the COVID-19 pandemic, meals were provided to residents in boxes at their room doors. Staff stated that due to the number of residents requiring meals and the facility still serving hot meals, some meals would get soggy or cold. Staff stated that caregivers assisted dining staff with delivering meals to get meals to residents more quickly, and attempted to serve meals that were supposed to be cold more often. Staff denied any issues with quality of ingredients or meal amounts during interviews, but stated that it was possible that residents felt limited in meal choice due to the delivery system. The Department was unable to interview R1 due to being unable to locate R1's whereabouts after R1 moved out of the facility. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).