complaint·February 2, 2024

Staff stated they know they should have checked the bottle and will read the label and not assume again. The resident’s physician was contacted and the resident was immediately placed on additional wellness checks. Wellness Director stated the staff was retrained and writte n up for the medication error. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility does not have adequate staff to meet residents needs. It was alleged that due to there being only one Med Tech for around 100 residents, they are too rushed due to providing so many medications to so many residents. It was also alleged that there are not enough staff to adequately meet residents needs and Resident 1 and Resident 2 (R1 and R2) were so neglected that they decided to hire private caregivers. It was also alleged R2 fell, was bleeding from their lip and no caregiver noticed it. Reporting party stated R2 has dementia and is on the highest level of care but staff are too busy to check on R2. LPA interviewed Staff and Residents. Most staff and residents stated the facility is under staffed. There are usually 2 staff scheduled, sometimes 3. Staff and residents stated sometimes staff call out and one caregiver has to cover all four floors and 90-100 residents by themselves. Staff and residents also stated they thought one med tech was not enough to meet all the medication needs of residents. Interviews with staff on 12/15/23 stated staffing has gotten better and now they are only left alone around once per week, not two or three times as was previously. Staff also stated they check on R1 and R2 multiple times a day in the AM and PM when they do not have their private caregiver. Administrator and Wellness Director stated when they discovered R1 and R2 hired private caregivers they tried to hold a meeting but family never wanted to meet. Administrator stated one medtech is enough because not every resident is on Medication Assistance. When asked about staffing Wellness Director stated they have two staff scheduled in the AM and PM and caregiver come mid shift if needed. LPA observed staff schedules from October through December 2023. LPA observed 2-3 caregivers and one med tech scheduled each shift. Administrator stated if there are any call outs Wellness Director or Wellness Coordinator come in and help cover. Based on the information obtained, the allegation is deemed Substantiated at this time due to multiple staff stating they are left alone to escort, respond to pendants, deliver food for almost 100 residents at least once per week. On the allegation: Facility did not follow admissions agreement. It was alleged that residents are not receiving housekeeping, there are often diapers on the floor and beds aren’t made. It was also alleged residents’ teeth aren’t being brushed, dressing assistance isn't being provided, and showers aren’t given per the Admission agreement. LPA interviewed staff and residents. Interviews revealed housekeeping comes and deep cleans once a week, and certain residents get daily housekeeping for an extra fee. Continued on 9099-C Staff and Residents stated housekeeping isn’t perfect but if a caregiver observes a dirty room they will call housekeeping to come clean it and they usually do. Staff interviewed stated there are some days (usually weekends) when there is only one housekeeper and they can’t clean everything so the caregivers have to. LPA interviewed Residents and Staff about grooming assistance. Staff stated they brush residents teeth daily and help get them up and dressed if needed per their care plan. When asked about showers staff state if a staff calls off, showers don’t get done and if someone refuses a shower they let the Med tech know and they try. LPA interviewed Med tech on 11/27/23, who stated today a resident refused a shower, they tried to shower them and they refused and was going to let the Wellness Director know. LPA asked if they inform the Medtech coming on (the following shift) that it was missed and Medtech said no, it’s the caregivers responsibility. LPA spoke to this resident who stated they did not refuse a shower they just didn’t want their feet to get wet. LPA asked if staff offered ideas on how to shower them without getting their feet wet and they stated no, that is their job to figure out. LPA informed the Wellness Director who stated they had already planned an in-service training on showers and will train staff to ask questions and overcome simple obstacles. Resident’s interviewed had mixed opinions on receiving their proper care and showers per admission agreement. Incontinent residents stated they don’t believe they are checked on every two hours. Residents stated they may be checked on 3-4 times throughout the day. Staff interviewed stated they try to complete everything on their Plan of Care (POC) but it’s hard to do everything with only 2 staff and they can’t be everywhere at once. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility is not kept clean. It was alleged that the dining room tablecloths are stained and dirty, not clean. LPA observed the dining room and tablecloths on 10/15/23 after breakfast, before lunch service. LPA observed four tablecloths to be dirty and stained. Staff interviews revealed they change tablecloths after lunch, before dinner and use a linen company. Staff stated the linen company sometimes send tablecloths with stains, and they have no choice but to use them. LPA recommended to staff to try and ask the company to not send dirty tablecloths or switch to a different color (other then white). On 12/15/23 LPA observed no dirty tablecloths. Based on the information obtained, the allegation is deemed Substantiated at this time. A technical Violation was issued. A civil penalty for a repeat violation for $250 was assessed. An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.