complaint·December 13, 2024

Review of Resident 1’s (R1's) documents revealed that R1 was had two assessments conducted in September 2020 and an additional care assessment in November 2020 due to increasing care needs. In September 2020, R1’s care needs included standby assistance for bathing, reminders for meals, and noted that R1 was a fall concern. During the November 2020 assessment, R1’s care needs increased to require full assistance from staff for all activities of daily living due to a fall. R1 was also placed on the facility’s waitlist for memory care, and communications between R1’s responsible party and physician dated October 2020 agreed that it was in R1’s best interest to be placed on the waitlist instead of relocating to a different facility. Additionally, R1’s responsible party had arranged for R1 to have a third party caregiver provide 1 on 1 supervision, which interviews with outside sources confirmed. R1 also began receiving hospice services sometime between November and December 2020. Review of fax communications revealed that R1’s physician and responsible party were kept informed of and were in agreement with R1’s increasing care needs. Interviews with outside sources revealed that there were some concerns regarding supervision, however, the concern was with the third party agency that was hired by R1’s responsible party and outside sources denied concerns with the facility staff's ability to meet R1's increasing care needs. Review of Resident 2’s (R2's) assessment records for October 2020 revealed that R2 required reminders for meals and dressing and required 1 person assistance for bathing. Review of R2’s physician report for December 2020 revealed that R2 had a diagnosis of major cognitive impairment, was confused and disoriented, had auditory and visual impairment and was occasionally incontinent. R2 was reassessed in January 2021 and review of R2’s physician report and needs and services plan from January 2021 revealed that R2 began receiving hospice services, required reminders for meals and toileting, required 1 person assistance for bathing and was at risk for falls. Review of fax communications between the facility and R2’s physician revealed that the facility maintained communication regarding R2’s changes in condition including falls. Review of Resident 3’s (R3's) physician’s report from August 2019 revealed that R3 had a diagnosis of mild cognitive impairment, was not confused or disoriented, was able to follow directions and communicate needs and was able to manage their medications independently. Review of fax communications revealed that beginning in September 2020, R3 was observed to have increasing confusion and agitation. Review of R3’s needs and service plans dated April 2021 revealed that while R3 did not have any increasing care needs, R3 required reassurance from staff to prevent agitation and distrust of staff. Review of assessment documents for R1, R2, and R3 did not reveal evidence that supported the allegation that residents were not appropriately assessed or that resident's appraisals were not updated to meet resident's care needs. Continued on LIC9099-C page... Review of the staff schedule for November 2020 revealed that the facility scheduled between 4 and 5 care staff including medication technicians per shift and scheduled between 2 and 3 care staff including medication technicians scheduled for the overnight shift. Interviews with residents did not reveal evidence that staff were not able to meet resident care needs and residents stated that staff were very attentive and helpful. Evidence obtained during interviews with outside sources corroborated that staffing level was sufficient to meet resident care needs. Interviews with staff were inconsistent regarding the ability of staff to meet the care needs of residents. Staff interviews provided conflicting information, with some interviews stating that the staff level during shifts matched the November 2020 staff level and other interviews revealed that there were multiple instances where there were approximately 3 caregivers during a shift, with one caregiver per floor in assisted living and one caregiver in the facility’s memory section. Review of the admission agreement used by the facility in 2019 and 2020 revealed that the facility agreed to provide residents with meals three times a day and in-between meal snacks. The admission agreement stated that meals would be provided "restaurant-style" in the facility's dining room or via tray service due to temporary sickness or at an additional fee. Additionally, the facility offered catering services to a resident's apartment or to a common area with prior notice and at an additional fee. Interviews with staff and residents did not reveal any concerns regarding the food quality, variety of options, or the facility’s ability to accommodate special diets. Review of the admission agreement revealed that the facility did not promise to provide a certain quality or level of dining experience to residents beyond providing meals in a restaurant like setting. 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). Review of a random sampling of residents’ assessment records, needs and services plans, and additional care assessment documents did not reveal residents who had wandering or exit seeking behavior that could not be managed by staff redirection. Review of incident reports submitted to the Department by the facility and review of licensing reports between September 2020 and December 2021 did not reveal any instances of resident elopements or wandering that resulted in injury. The Department has investigated the above-mentioned allegation and based on record review, this allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. 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).