Inspector’s narrative
What the inspector wrote
Interviews revealed R2 often exits the facility from a side entrance/exit to smoke outside; and, the entrance/exit does not have an alarm even though the facility has residents with dementia. Based on records reviewed and interviews, due to a lack of supervision, on multiple occasions R2 wandered to a residence known to R2 approximately ¼ mile from the facility. R2 was unaccompanied by facility staff when R2 left the facility premises, even though R2 had dementia and was sometimes confused. Based on records reviewed and interviews conducted, the allegation that staff failed to prevent resident from wandering is Substantiated at this time.
Allegation: Facility failed to provide adequate food service. The concern is that the food is inappropriately rationed, it does not appear to be of good quality, and it is not tasty or appetizing. On 7/9/2019, at approximately 12:35 pm, LPA observed a minimal amount of food in the refrigerator located inside the kitchen of the facility. LPA observed in the refrigerator three containers of butter/margarine, cheese, six eggs, pancake mix, one large pitcher of drink mix, one gallon of milk with approximately 1/8 gallon remaining, one loaf of bread, half of a watermelon wrapped in a paper towel, tomatoes, a jar of grape jelly, one jar of mustard, one jar of mayonnaise, one bottle of ensure, and four small containers of garlic spread. LPA observed in the pantry one box of Bisquick, two boxes of hot chocolate mix, one box of equal, Lawry’s seasoned salt, a jar of sandwich spread, a box of pasta, eleven bottles of Ensure, one can of green beans, one can of whole kernel corn, four cans of spam, one bottle of syrup, one can of Vienna sausages, one box of Raisin Bran Crunch, one container of cornmeal, one container of split green peas mix, one container of freeze dried mango, five onions, and four cans of pork and beans. LPA observed there were no fresh or frozen meats, or other frozen foods. Interviews conducted revealed that the food in the garage is mostly used for the facility next door, also owned by Licensee/Administrator, and Licensee/Administrator allocates the food to staff for use in this facility. Interviews revealed food served was unrecognizable as to what it was, food served appeared to be spoiled and had a “sour” smell, and toast was served with no butter (not by choice). Additionally, fried chicken was purchased and served to residents with special diets such as consistent carbohydrate diet for diabetes, and no added salt or low salt. Based on five (5) out of six (6) interviews conducted, the allegation that Licensee/Administrator did not provide an adequate amount of food and food was of poor quality is Substantiated at this time.
Continued on 9099C.
Allegation: Medications not given as prescribed. The concern is that R1 is aware of the medications they are taking, and R1 stated staff did not provide R1 with all of R1’s medications. R1 also stated R1 had to remind staff when medications should be given. LPA reviewed the facility Medication Administration Record (MAR). R1 was prescribed Carvedilol 125 mg one tablet every 12 hours, hold if systolic blood pressure (SBP) <110 or heart rate (HR) <60. The MAR indicates R1 did not receive the AM or PM dose of this medication on 07/02/2019, and did not receive the AM dose on 07/03/2019. The MAR does not indicate the medication was held due to low blood pressure or a low heart rate, and there are no additional notes in R1’s file indicating blood pressure measurements were taken. The MAR does not indicate the medication was refused. R1 was prescribed Symbicort 160/4.5 inhale 2 puffs every 12 hours by mouth. The MAR indicates R1 did not receive the AM or PM dose of this medication on 07/02/2019, and did not receive the AM dose on 07/03/2019. The MAR does not indicate the medication was refused. R1 was prescribed Quinapril 40 mg take one tablet daily, hold if systolic blood pressure (SBP) <110. The MAR indicates R1 did not receive the daily dose, taken in the AM, of this medication on 07/02/2019. Based on the information obtained, the allegation that medications are not given as prescribed is Substantiated at this time.
Allegation: Facility failed to provide comfortable accommodations for residents. The concern is that R1 and R1’s outside agency representatives were told that the home was wheelchair accessible, including the bathrooms; however, the bathroom door did not accommodate a standard sized wheelchair. In addition, R1’s hospital bed did not work properly, and the remote control for the TV in R1’s room was not the correct remote for R1’s TV. Based on observation and measurement, LPA noted R1 was unable to access the bathrooms of the facility. R1 requires an extra wide wheelchair rather than a standard 32-inch wheelchair; however, the doors to the facility bathrooms are approximately 28 inches in width. Even though the facility has non-ambulatory fire clearance, a standard wheelchair cannot fit through the bathroom door. LPA also observed that the remote control for R1’s TV did not work. Based on observation, interviews conducted and records reviewed, R1 is non-ambulatory, requires 1-2 person assistance with toileting and showering, experiences incontinence. Staff interviewed stated they do not have the physical strength to lift R1 to/from R1’s wheelchair. Facility staff placed a portable commode in R1’s room due to the bathroom’s inaccessibility, and outside agency representatives came to the facility to shower R1 due to the facility staff being unable to shower R1. Based on observation, measurement, interviews conducted, and records reviewed, the allegation that facility did not provide comfortable accommodations for residents is Substantiated at this time.
Continued on 9099C.
Allegation:
Administrator speaks inappropriate towards residents.
The concern is that Licensee/Administrator appears to speak to residents in a threatening tone. Interviews revealed eight (8) of the ten (10) individuals stated that Administrator’s comments made to residents or in front of residents are perceived to be of sarcastic nature, inappropriate, confrontational, demeaning, disparaging, disrespectful, and impolite. Interviews conducted revealed Administrator yelled and argued with one resident who was displaying mental decline in the presence of others. On 7/9/2019, at approximately 11:40 am, LPA observed Administrator speak harshly to R2 when R2 was inquiring as to when they would be leaving for a medical appointment. In the presence of facility staff and other residents, LPA observed Administrator verbally snap at R2 telling R2 there was no appointment scheduled. R2 appeared to be confused because prior to the 11:40 am incident with R2, LPA observed staff tell R2 that R2 had a doctor’s appointment in order to get R2 to agree to take a shower--R2 complied with staff and took a shower. Based on interviews and observation, the allegation that Administrator speaks inappropriate towards residents is Substantiated at this time.
Allegation:
Staff fail to properly maintain the facility. The concern was that R1’s room was unclean, cluttered, unkept, and the driveway and garage reportedly looked like a “junkyard”. Interviews conducted revealed that upon the time of R1’s admission into the facility, R1’s room was overcrowded with furniture making it difficult to move about the room, the room was not clean and had spider webs and dirt in multiple areas of the room. The bed hand-crank was broken and was repaired by a family member. The television remote control did not work. Additionally, seven (7) of the eight (8) interviews conducted revealed that the facility driveway and garage had debris, broken furniture, and other various items. Based on interviews conducted, the allegation that the facility staff did not maintain the facility is Substantiated at this time.
Exit interview, deficiencies cited on 9099-D, report emailed, appeal rights emailed.
Per credible and reliable witnesses interviewed, R1 is mentally alert, able to communicate one’s needs, has no cognitive issues, has involved family members and did not give permission and did not want Licensee/Administrator to be present during medical appointments. Even though Licensee/Administrator insisted on accompanying R1 to medical appointments, Licensee/Administrator did not accompany R1 to the appointments. Therefore the allegation is Unsubstantiated at this time.
Allegation: Facility not ensuring resident attends scheduled appointments. The concern is without R1’s knowledge or permission, Licensee/Administrator changed a previously scheduled medical appointment without discussing it with R1 and without R1’s consent. R1 did not want Licensee/Administrator attending R1’s medical appointments, and had expressed this to Licensee/Administrator. Interviews conducted revealed that Licensee/Administrator re-scheduled a follow-up medical appointment for R1. Licensee/Administrator changed the appointment due to it being “inconvenient” for her; and, upon inquiry as to why it was changed, Licensee/Administrator stated she was required to be present at the appointment so she would know if there was something specific she needed to know about R1’s care. Interviews conducted revealed that R1 did not sign an acknowledgement granting consent to have Licensee/Administrator present during medical appointments. A representative from an outside agency was able to retrieve R1’s medical appointment and transported R1 to the appointment. Licensee/Administrator became confrontational towards the outside agency representative and towards R1 when Licensee/Administrator observed them as they were leaving the facility to go to the appointment. Further interviews conducted revealed that Licensee/Administrator exclaimed to R1 and the representative that R1 was not supposed to be outside the facility and that she was supposed to be present at R1’s medical appointment. Licensee/Administrator sent a text message to the representative stating “You are a piece of work.” Based on the evidence obtained, the allegation that facility personnel did not ensure resident attends medical appointments has been Unsubstantiated at this time. However, the personal rights violation of cancelling R1’s medical appointment without consent or R1’s authorization is addressed on a Case Management - Deficiencies visit dated 07/22/2021.
Exit interview, report emailed.
