complaint·February 27, 2025

On 05/31/2024, LPA reviewed R1’s facility charting notes dated 05/24/2024, stating “ ***Late entry from 05/23/2024*** Resident apartment had strong ammonia like odor upon entrance. This may have been due to pervious alleged urination onto the PTAC unit in (R1’s) apartment. PTAC unit was removed, pressure washed, sanitized and then installed back in place. A urine odor removal spray was also applied. On May 24th the odor appears to have reduced. – Serviced on May 23, 2024 at 01:00PM”. At this time there in enough evidence to support the allegation of, “Staff do not ensure that the facility is maintained sanitary.” and is substantiated at this time. Exit interview, report read, citation issued, report and appeal rights provided. S6 also stated that there is no physician prescribed diets at this time. On 06/10/2024, LPA Jeffries conducted interviews with Residents 6, 7, 8, and 9 (R6, R7, R8 and R9) all stated that the food is of good quality, size and verity. On 05/23/2024, LPA Jeffries conducted interviews with S5 and S6 who both stated that the food the facility provided is of good quality, verity, and proportions. LPA reviewed facility weekly meal plans from April through May of 2024 that list a varied meal services with a verity of food choices. On 06/02024 LPA Jeffries reviewed facilities annual diet and culinary services audit with a 95.45% score. At this time there not enough evidence to support the allegation of, “Staff do not ensure that residents’ dietary needs are met.” and is unsubstantiated at this time. As to the allegation of, “Staff do not ensure that residents’ incontinence needs are met.” It was alleged that, Resident 1 (R1) and R2 rooms “smelled like poop” because of the residents urinating and defecating everywhere. It was discovered through interviews, observation and documentation that on 05/23/2024 LPA Jeffries conducted interviews with Direct Care Staff 1 (S1) who stated, Both R1 and R2 have exhibited behaviors that involves handling their stools. S1 stated that both residents Physicians have been notified of the behaviors, all care staff have been addressing the behaviors as they happen, and house cleaning staff attend to the residents as needed. S1 also stated that they can call housekeeping at any time for emergency clean ups in memory care. On 05/23/2024, LPA Jeffries conducted an interview with Administrator Carl Meyer who stated that the housekeeping staff is available and will respond when called to do emergency clean ups in memory care unit as needed. On 06/10/2024 LPA conducted interviews with S2, S3, and S4 all who stated that Resident incontinence is always addressed when needed, basic clean up is done by care staff, and housekeeping is available for emergency clean up on request. On 05/23/2024, 06/10/2024, and 08/19/1014 LPA Jeffries observed sufficient direct care staffing in memory care unit. On 05/31/2024 LPA reviewed staff training records to be current and within regulation standards for direct care staff interviewed. At this time there is not enough evidence to support the allegation of, “Staff do not ensure that residents’ incontinence needs are met.” and is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Staff do not ensure that residents are provide with a safe environment.” It was alleged that, R4 makes sexually inappropriate comments to residents and staff. It was discovered through documentation and interviews that on 05/23/2024 LPA Jeffries conducted an interview with S1 who stated that all memory care staff have been educated and trained on intervention techniques with R4’s behaviors. Staff have been instructed to redirect R4 when these behaviors are exhibited. On 05/31/2024 LPA reviewed staff training records to be current and within regulation standards for direct care staff interviewed. LPA reviewed R4’s facility care level service plan which indicated that R4 has a moderate assist for these behaviors. Additionally, there are facility notes addressing daily behaviors of R4 with a specific of date May 16th addressing the frequency of these behaviors. Additionally, there is a note on 05/23/2024 pertaining to medication changes and possible consideration for eviction due to not being able to meet increasing care needs if they persist. LPA noted that on 05/23/2024, 06/10/2024, and 08/19/1014 LPA Jeffries observed sufficient direct care staffing in memory care unit. At this time there in not enough evidence to support the allegation of, “Staff do not ensure that residents are provide with a safe environment.” and is unsubstantiated at this time. As to the allegation of, “Staff do not provide residents with activities.” It was alleged that facility does not provide memory care with activities. It was discovered through interviews, documentation and observation that on 05/23/2024 LPA Jeffries interviewed S1 who stated that memory care has scheduled activities every per day. On 05/23/2024, 06/10/2024, and 08/19/1014 LPA Jeffries observed sufficient direct care staffing in memory care unit and activities for residents being conducted. LPA noted by observation that not all residents participated in the scheduled activities. On 06/10/2024, LPA Jeffries conducted interviews with S2, S3, and S4 who all stated that the facility provided daily activities for memory care residents. On 05/31/2024 LPA Jeffries observed facility activities schedule for memory care. At this time there in not enough evidence to support the allegation of, “Staff do not provide residents with activities.” and us unsubstantiated at this time. Exit interview, report read, and report provided.