complaint·February 24, 2022

On 09/22/2020, from 11:35 a.m. to 1:35 p.m., LPA Jeffries conducted the initial complaint visit telephonically with Executive Director/Administrator, Michael Mayfield. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint visit was conducted telephonically and through FaceTime. LPA Jeffries conducted a physical plant tour from 11:35 am to 1:35 pm and requested copies of pertinent documents relevant to the investigation and took photographs of Resident 1’s (R1) room. During Investigator Rippe’s investigation, interviews were conducted, medical reports were obtained and reviewed. Investigator Rippe conducted interviews with R1’s responsible party on 10/06/2020 at 7:25 a.m. and 12:20 p.m.; and with R1 at 12:02 p.m.; with staff on 10/15/2020 at 1:00 p.m.; with Regional Director of Operations on 10/20/2020 at 3:16 p.m. and on 10/22/2020 at 10:07 a.m.; with staff on 10/22/2020 from 11:26 a.m. to 12:47 p.m.; with the Executive Director/Administrator on 10/29/2020 at 8:56 a.m.; with staff on 11/04/2020 at 12:57 p.m.; and with staff on 11/13/2020 from 8:37 a.m. to 3:21 p.m. On the allegation: Resident sustained multiple pressure injuries while in care - The Wilshire Home Health (HH) reports for September 2020 stated that R1 had a stage two pressure injury on right buttocks, a stage one pressure injury on sacrum, and a stage one pressure injury on coccyx area. According to the last report from HH on 09/29/2020 the pressure injuries has been staged as a 3 by a Medical Doctor. Based on this information, the Department has sufficient evidence to support the above allegation. Therefore, the allegation is deemed Substantiated at this time. On the allegation: Resident’s diapering needs were not being met- HH records revealed on 08/25/2020 R1 was assisted in brief change during transfer to toilet resident was soiled with stool and HH staff held a conference with the facility staff Medication Technicians (MT) and Resident Assistants (RA) about R1 not being aware of loss of control and asked staff to visually inspect briefs for adequate hygiene and infection process. Continued 9099-C Witness 1's (W1) interview revealed R1 was soaked with BM's on every visiit. HH reports for the beginning of September 2020 stated R1 had a stage two pressure injury on right buttocks, stage one pressure injuries on sacrum and coccyx area as of 09/29/2020 the pressure injuries were not healing and had been staged as a 3 by MD. Staff interviews revealed 3/7 staff stated R1 was found soiled on several different occasions. Based on the information, the Department has sufficient evidence to support the above allegation. Therefore, the allegation is deemed Substantiated at this time. On the allegation: Staff not responding to residents call button in a timely manner – The facility provided copies of the call log for R1. From the time period of 09/04/2020 to 09/06/2020, the staff response time to R1’s call button ranged from 9 to 25 minutes, which indicates an untimely staff response. Based on this information, the Department has sufficient evidence to support the above allegation. Therefore, the allegation is deemed Substantiated at this time. On the allegation: Staff not providing appropriate bed accommodations for resident – Staff admitted moving R1’s mattress to the floor to prevent injury to R1 falling out of bed. There was no Dr. order or letter of support from the responsible party to move the mattress to the floor. Based on this information, the Department has sufficient evidence to support the above allegation. Therefore, the allegation is deemed Substantiated at this time. On the allegation: Facility is not kept free of pests- Based on LPA Jeffries observation, tour of the facility with the Administrator and 12 photographs LPA took of room 111 showed bugs, dead bugs, and spider webs present. Administrator confirmed this to LPA Jeffries that there were cobwebs on the curtains and window seals. Based on the evidence the allegation is deemed Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator. On 09/22/2020, from 11:35 a.m. to 1:35 p.m., LPA Jeffries conducted the initial complaint visit telephonically with Executive Director/Administrator, Michael Mayfield. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint visit was conducted telephonically and through FaceTime. LPA Jeffries conducted a physical plant tour from 11:35 am to 1:35 pm and requested copies of pertinent documents relevant to the investigation. The physician’s report dated 08/23/2018. Investigator Rippe conducted interviews with R1’s responsible party on 10/06/2020 at 7:25 a.m. and 12:20 p.m.; and with R1 at 12:02 p.m.; with staff on 10/15/2020 at 1:00 p.m.; with Regional Director of Operations on 10/20/2020 at 3:16 p.m. and on 10/22/202 at 10:07 a.m.; with staff on 10/22/2020 from 11:26 a.m. to 12:47 p.m.; with the Executive Director/Administrator on 10/29/2020 at 8:56 a.m.; with staff on 11/04/2020 at 12:57 p.m.; and with staff on 11/13/2020 from 8:37 a.m. to 3:21 p.m. On 07/02/2020 at 8:30 p.m., R1 was getting coffee in R1’s assisted living apartment and slipped on some coffee that had spilled on the floor. R1 was ambulatory and able to walk using a walker on own prior to July 2020. R1 was taken to Twin Cities Hospital, where an x-ray was taken and noted that R1’s right femur was fractured. R1 had open reduction and internal fixation (ORIF) surgery to place a rod in the femur and was then transferred to Mission View Rehabilitation from 07/08/2020 to 07/29/2020. R1 returned to Creston Village Assisted Living on 07/29/2020. R1 was not able to walk and was in a wheelchair. R1 returned to the same assisted living apartment. R1 required more care upon return to the facility. The administrator denied telling R1’s responsible party there would be two staff with R1 at all times. Staff stated they checked on R1 every 30 to 60 minutes. Staff stated when R1 returned from the rehab facility, R1 would throw self out of bed and onto the floor and hid pendant from staff. Due to these behaviors, staff moved R1’s mattress to the floor. Per Home Health notes, R1 had 3 falls since returning from the rehab facility. R1 stated to the Home Health nurse that R1 was intentionally throwing self out of bed in order to cause self-harm. Continued 9099-C On 09/05/2020, R1 was found on the floor of R1’s assisted living apartment, was taken to Twin Cities Community Hospital and diagnosed with a left proximal humerus fracture. Hospital notes state “patient fell out of bed onto floor, has a history of falling out of bed, patient mental status has been declining since recent rehab admission after leg fracture 2 months ago”. During the visit, R1 was also diagnosed with a urinary tract infection (UTI). Investigator Rippe requested and reviewed medical records pertinent to the investigation and conducted interviews. R1 admitted to rolling out of bed and going to the hospital while living at the facility. R1 was unable to provide any further details. The former Executive Director/Administrator, Michael Mayfield, gave the approval for R1 to return to the facility from the skilled nursing facility. He did not promise R1’s responsible party that there would be two staff members with R1 at all times. Information provided through interviews found that R1 would throw self out of bed and onto the floor, which led staff to place mattress on floor to prevent injury. Investigator Rippe found no evidence of neglect or lack of supervision regarding R1’s care. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegation. Therefore, the above allegation is deemed Unsubstantiated at this time. Exit interview, copy of report given.