complaint·July 3, 2024

Staff neglect led to hospitalization of resident: Staff did not seek medical attention for a resident in a timely manner: The facility was alleged that staff neglect and led to R1's hospitalization, and staff did not seek medical attention for R1 in a timely manner. Resident R1 was admitted to the facility on 04/28/2023. R1 was able to ambulate with cane and was able to feed self. On 05/31/2023, R1 was tested COVID positive and was isolated in his/her room. As R1's COVID progressed, R1 was getting weaker. R1 was unable to feed self without staff assistance and was unable to ambulate. On 06/21/2023, two friends of R1' family member visited R1 and found R1 was weak and was unable to get out of bed. R1's visitor called 911 when R1's visitor visited R1. Based on the interviews conducted on 11/06/2023 and 11/14/2023 with Executive Director, Director of Resident Care Services, and the charge nurse, Executive Director and Director of Resident Care Services admitted that staff did not follow protocol regarding R1' change of condition and did not read the staff notes from the previous shifts regarding R1's condition. Staff S1 admitted that he/she did not read the staff notes from the previous shifts and that based on the previous staff notes, R1 should have been sent to hospital based on R1's declining condition. Staff documented R1's change of condition but did not report R1's change of condition to Executive Director or Director of Resident Care Services. Continue on LIC9099-C. Page 2 of 3. The Department has investigated the above allegations. Based on records reviews, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC9099-D. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty for violation resulting in serious bodily injury is pending review. Exit interview was conducted with ED. The report was provided to ED for signature. This report, LIC9099-D, and Appeal Rights were provided to ED. Page 3 Staff did not ensure resident was fed, resulting in significant weight loss: Resident R1 was admitted to the facility on 04/28/2023. R1 was able to eat and feed self. On 05/31/2023, R1 was diagnosed with COVID and was isolated in his/her room. As R1's COVID progressed, R1 was getting weak and was unable to feed self without staff's assistance. On 1/18/2024, the Department interviewed 5 staff. 4 out of 5 staff stated caregivers and Med Techs fed R1 during R1's isolation in his/her room. 1 out of 5 staff stated R1 did not lose weight during R1's stay in the facility. Resident R1 was eating less portion than usual. Facility staff encouraged R1 to eat more during R1's isolation period. Based on R1's weight records on May 2023, and June 2023, R1's did not lose weight during R1's isolation period. Staff do not maintain the facility in clean and sanitary condition: On 05/31/2023, resident R1 was tested COVID positive and was isolated in his/her room. It was reported that during R1's isolation period, R1's room was not maintained in clean and sanitary condition. On 1/18/2024, the Department interviewed the temporary Executive Director (TED). TED stated during the COVID isolation period, housekeepers do not enter the resident isolation room to conduct deep cleaning until they receive notice that the resident is out of isolation. The Department interviewed 5 staff. 5 out of 5 staff stated housekeepers did not enter R1's room to conduct deep cleaning during R1's isolation period. 3 out 5 staff stated caregivers cleaned R1's room during R1's isolation period. The caregivers took out plates, bowls, trays, and took garbage out from R1's room during R1's isolation period. Continue on LIC9099-C. Page 2 of 3. Staff did not notify resident's responsible party of a change in condition: On 1/18/2024, the Department interviewed the facility temporary Executive Director (TED). TED stated the facility received a notice from R1's main contact (FM1) stating that the facility to contact R1's second contact starting from 5/19/2023 due to FM1's out of country. The Department interviewed resident R1's second contact (FM2). FM2 stated he/she received a phone call from the facility regarding R1's health condition. FM2 stated he/she is not sure how many times the facility called him/her because he/she was also on vacations during the time FM1 was out of country. The Department interviewed staff S1. S1 stated he/she notified FM2 that R1 has a change of condition. Based on the record reviewed, a note was provided to the facility to contact R1's second contact due to R1's main contact is out of the country. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted for today’s visit. Exit interview was conducted with ED. A copy of this report was provided to ED. Page 3 Out of 3.