complaint·April 13, 2025

Report Continued from LIC 9099... It was alleged that staff did not manage resident's care needs while in care. It was reported that R1 was not being provided with pain medication or hygiene care by the facility staff. Records reviewed and staff interviews revealed that facility staff provided R1 with showers twice a week. Upon R1’s admission to hospice care, the care plan was updated to include showers twice weekly, provided by the hospice nurse. According to the hospice care plan dated 01/07/2024, the hospice nurse was responsible for assisting R1 with hygiene, personal care, homemaking tasks, and providing showers twice per week. A review of the hospice flow sheet showed that R1 received either a shower or a bed bath from the hospice nurse on 01/08/2024, 01/15/2024, and 01/17/2024, indicating that the hospice team was not consistently following the care plan regarding hygiene and bathing. Interviews with facility staff also revealed that aspirin is typically prescribed as a routine medication rather than on a PRN (as-needed) basis. Staff stated that R1 was administered aspirin daily with morning medications until their doctor ordered the discontinuation of most medications, including pain medications, due to R1's difficulty swallowing. At that point, R1 was transitioned to comfort medications. The care plan further stated that the hospice nurse was responsible for assisting with pain and symptom management, assessing vital signs during each visit, and reporting any unrelieved pain despite rest and prescribed medications. Additionally, documentation from an outside agency / hospice notes dated 01/08/2024 indicated that R1 showed no signs of pain or distress during the hospice nurse’s visit. Furthermore, interviews with five out of five residents revealed no concerns regarding the administration of their daily medications. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not manage resident’s care needs while in care”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff handled resident in a rough manner. It was reported that staff were observed grabbing Resident 1 (R1) roughly while providing care. Interviews conducted with staff revealed that no residents had reported being handled inappropriately or too roughly while receiving assistance. Additionally, staff stated that residents regularly communicate with their family members, and no complaints have been received from families regarding rough handling. Interviews conducted with residents indicated that they had not observed staff handling other residents roughly, nor did they feel that staff were too rough when assisting them. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Residents further stated that staff are nice, polite, and courteous when responding to requests for assistance. Furthermore, five out of five residents interviewed reported no concerns about living at the facility. Based on the information obtained, the Department has insufficient evidence to support the allegation of “staff handles resident in a rough manner”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff did not follow resident's special diet. It was reported that R1 was unable to swallow, resulting in solid food and vomit remaining in R1’s mouth. It was further reported that R1 should not have been given solid food due to the risk of choking. Records reviewed and staff interviews conducted revealed that R1 had a tendency to pocket food and medications. According to a facsimile provided, staff were in regular communication with R1’s primary care physician (PCP) and reported any changes in R1’s condition. On 07/20/2023, the facsimile shows that facility staff reported R1’s food and medication pocketing behavior, which led the PCP to update care orders on 07/21/2023 to crush medications and modify R1’s diet to mechanical soft. Staff continued to communicate changes in R1’s condition with the PCP, as evidenced in a facsimile dated 01/02/2024, in which staff reported that R1 was no longer able to retain food or fluids and continued to vomit. On 01/05/2024, staff reported that R1 was still vomiting and unable to keep down food or fluids, despite the PCP’s updated order on 01/03/2024 to administer two (2) Ensure nutritional drinks five (5) times daily. Interviews with staff confirmed that R1 was assisted with feeding on a daily basis. Staff closely monitored R1 while eating, observing for signs of choking, as R1 frequently struggled with swallowing. Furthermore, staff maintained consistent communication with R1’s physician and followed medical orders as they were received. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not follow resident’s special diet”. Therefore, this allegation is deemed Unsubstantiated at this time. It was further alleged that staff left resident slumped over in their wheelchair for extended time periods. It was reported that R1 was left slumped over in their wheelchair by the dining table for extended periods, up to eight (8) hours. Interviews conducted with staff revealed that residents are escorted to the dining room for meals each day unless they are able to get there independently. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Staff stated that residents typically participate in activities after breakfast until lunchtime. Following lunch, residents are returned to their rooms to nap or rest until dinner, which is served a few hours later. Staff further explained that most residents in the memory care unit are incontinent and are therefore checked at least every couple of hours to ensure they are dry and to reposition them as needed. Interviews also indicated that when residents are taken back to their rooms, they are not left sitting in their wheelchairs. Instead, they are transferred to either their beds or recliner chairs to allow them to rest and relieve pressure on their backs and bottoms. Additionally, during a visit conducted on 04/12/2025, the LPA observed residents being returned to their rooms and appropriately transferred to their beds for rest. Based on the information obtained, the Department has insufficient evidence to support the allegation of “staff left resident slumped over in their wheelchair for extended time periods”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy provided.