complaint·February 28, 2025

The number of days, hours, and frequency varied and was dependent on the resident and resident’s responsible party. Most of the interviews conducted did not reveal any concerns with the agreements not being followed. One source revealed an instance when a caregiver providing one to one assistance was asked to assist other caregivers. The resident being provided one to one assistance was escorted to a common area where other residents were supervised by staff. A separate source recalled an instance where the assigned one to one caregiver was asked to assist with meal prepping. The staff agreed and the resident being provide one to one assistance remained in the common area, within eyesight of the caregiver. Although the residents remained under staff supervision, the agreement of one-to-one care was not followed. This deficiency was cited in an LIC 9099D page and a plan of correction was jointly formulated with the Executive Director James Arp. An exit interview was conducted with James Arp, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by James Arp. R1’s Physician’s Report (LIC 602) dated July 12th, 2022, revealed a primary diagnosis of Hyperlipidemia (HLD), Spinal Stenosis (cervical), and Sciatica. A secondary diagnosis of Gerd, and Neuropathy of fingers. No cognitive impairment was disclosed in this report. A records review that included the facility and nurses’ notes dated March 13th, 2023, revealed that R1 was found on the floor by staff, who summoned Emergency Medical Services (EMS). The facility and nurses notes further revealed that on March 14th, 2023, upon R1’s request, staff transported R1 to urgent care with complaint of pain. An X-ray revealed R1 had a rib fracture and medication was prescribed. R1 declined further testing and denied any head injuries had occurred. Interviews with staff confirmed that staff responded to R1’s call for help, evaluated R1 and EMS was summoned. Interviews with staff and R1’s relative confirmed R1 had a history of declining medical assistance and often declined to be transported to the hospital for further evaluation. During this incident, Staff and a relative encouraged R1 to obtain medical evaluation from emergency personnel, but R1 continued to decline further evaluation. Based on evidence obtained, staff responded quickly, evaluated R1 and summoned EMS. R1 was R1’s own responsible party and declined further medical attention, therefore, the allegation was Unsubstantiated. It was alleged neglect resulted in R1 receiving delayed medical care. During R1’s fall on March 18th, 2023, there were no visible injuries, but R1 complained of right-side pain. Staff were unable to determine if R1 struck their head during the fall. Paramedics were immediately called and assessed R1 for injuries. Paramedics advised R1 to be transported to the hospital for further evaluation, but R1 refused. R1’s relative was called while paramedics were still present and tried to convince R1 to be transported to the hospital for evaluation. R1 still refused. R1 was their own POA and in charge of their own medical care. The evidence shows that R1 was immediately provided emergency services after the fall, but R1 declined further evaluation against the paramedic’s advice. Therefore, the allegation of Neglect/Lack of Care and Supervision resulting in untimely medical care was Unsubstantiated. It was alleged staff did not meet resident's toileting needs. Interviews with several sources, including staff and residents, denied having concerns with lack of incontinence care, or with lack of assistance with toileting. Sources consistently reported staff would respond within a reasonable time to residents’ requests. The allegation was unsubstantiated based on the evidence obtained during the investigation. An exit interview was conducted Executive Director James Arp, to whom a copy of this report was provided via email. An email read receipt confirms the documents were received by Arp.