Complaint·June 11, 2024

F1 also stated R1’s hospice nurse did not tell them this either. F1 stated they were promised by the hospice nurse they would discuss any changes in R1’s care with them, but F1 was never contacted about anything. F1 stated when she told the facility’s now former Executive Director (ED) about the issues, the ED suggested to have a meeting with R1’s providers. F1 stated on 10/2/20 they saw R1 in an ambulance and realized R1 was dying. F1 said they had not received any word of R1’s condition from the hospice social worker or hospice nurse, and R1’s body again smelled like rotting flesh. R1’s hospice nurse and hospice social worker did not work for the facility. Although the allegations may have happened, there was insufficient evidence to prove the allegations occurred. Therefore the allegations are deemed Unsubstantiated at this time. On the allegation: Staff did not assist resident in care with their hygiene needs. F1 indicated during R1’s last week at the facility, their “skin has the smell of rotten flesh.” F1 asked staff if R1 was being cleaned, and staff said yes. F1 stated on 10/2/20, they saw R1 in an ambulance and realized R1 was dying. F1 stated R1’s body again smelled like rotting flesh, and they believe because R1 was “rotting from the inside.” F1 said they had not received any word of R1’s condition from the hospice social worker or hospice nurse. F1 believed R1 was not bathed on the weekends. R1’s physician’s report dated 8/15/2019 indicates R1 needs assistance with bathing. R1’s hospice care plan dated 6/15/2020 indicates R1 needs assistance with bathing in the shower. An updated facility care plan dated 9/15/2020 indicates R1 needs 2 person assist with bathing and it was performed by an outside agency (hospice). Another page of the document confirms it was hospice’s responsibility to shower R1 three times per week per the care agreement. There was no documentation or notes in R1’s files to suggest they refused bathing or were not bathed regularly. Although the allegation may have happened, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not administer medication(s) to resident according to physician's instructions. It was alleged that R1 was not provided their medications as prescribed. Continued on 9099-C F1 stated that the administrator called them to notify them R1 fell out of bed, was picked up and put back to bed without waking. F1 indicated there was a second incident where R1 fell out of bed onto the floor without waking. F1 stated they think R1 could have been overmedicated. Per F1, R1’s personal doctor called them also stating the concern of being overmedicated. F1 indicated when R1 entered the facility, they could walk, talk and feed self, and two weeks later they could not do any of those things. Previously R1 could video chat every day, but after they could not lift their head to talk and was often sleeping. F1 also stated medications that were discontinued were still given by staff that were unaware of the change. F1 stated that R1’s hospice nurse made a remark that they could take all of R1’s medications away and “let nature take it’s course,” and F1 also stated they believe the hospice nurse did stop giving R1 medications. LPA reviewed medication orders for R1 dated 6/15/2020, and reviewed documentation in R1’s file. There was no documentation to suggest medication was not given as prescribed. LPA reviewed incident reports for 2020 and did not find any report of medication not given as prescribed. Although the allegation may have happened, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not feed resident while in care. It was alleged staff did not feed a resident in care. F1 stated they were told R1 was actively dying and saw R1 writhing in pain. F1 believed R1 was not dying, but was having hunger pains. F1 stated a staff told them the facility staff have no patience feeding the residents. F1 stated one evening they went to visit R1 at 5:30pm and were told R1 was already in bed and did not eat dinner. F1 indicated R1’s hospice nurse told staff not to feed R1. F1 asked R1’s hospice nurse if R1 could be taken to the hospital to get fluids, but was told hospice does not do that. F1 brought protein shakes for R1 but stated they were not given to R1. R1’s physician’s report dated 8/15/2019 states they are “borderline” able to feed themselves. R1’s hospice care plan dated 6/15/2020 indicates R1 feeds self. On subsequent visits to the facility, LPAs observed an adequate amount of food in the kitchen on annual inspections on 2/25/2022, 2/21/2023, and 1/30/2024. Continued on 9099-C No staff interviewed indicated residents’ care needs were not met. Although the allegation may have happened, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Facility did not have enough staff to meet the needs of resident(s) in care. F1 stated they did not believe there was enough staff for their staff to patient ratio. F1 stated they watched a resident sit alone on the patio for a half hour and staff did not come check on them. F1 believes this is because the staff must supervise, feed and clean residents, clean up after meals and do housekeeping duties. LPA was unable to determine which resident F1 described. On a visit on 5/6/2024, LPA observed a resident sit outside on the patio and observed staff routinely check on the resident through the windows. Former Administrator stated around 2020, there were only two staff working the afternoon shift. Former Administrator stated they asked for more staffing, but corporate did not approve it at the time. Staffing was increased in March 2022 so that both the morning and afternoon shift had two caregivers and one med tech. Former Administrator stated when they had fewer staff on shift, she worked the floor and staff members worked overtime to ensure residents were cared for. Former Administrator stated they ensured resident care was not affected, saying it was hard on the staff but nothing fell through. Although the allegation may have happened, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time.