complaint·March 11, 2022

Continued from LIC9099A Staff mishandles resident's medications – Complaint alleges that resident was given incorrect dosage when they initially moved into the facility indicating that medication for blood pressure was given twice per day when it was supposed to be given once per day and that medications were sometimes left in R1’s room while they were sleeping. Per interviews, upon move-in, medications were not in their original containers causing facility Administrator and responsible party to have to meet and organize medications. Interviewed staff denied leaving medications in resident rooms and stated that they stay with the resident until the medications are taken. Review of the documents pertaining to medications showed that blood pressure medication was to be given twice per day. Facility is not being maintained in a safe and sanitary manner – Complaint alleges that resident’s mattress did not have a mattress cover on it resulting in the mattress being stained by urine and that the carpet was stained and retained a urine odor. Additionally, that resident’s bathroom was not cleaned as needed and food was left around the apartment. Per staff interviews, the facility cleaned the mattress with an industrial cleaner and staff did not observe urine on the carpeted floor. LPA observed that involved resident’s room did not smell of urine during February 2, 2022 visit. Resident’s mattress had a faint stain but did not smell of urine. LPA did not observe any stains on the carpet. Administrator confirmed that there was not a mattress cover on the mattress due to it being in the wash. Per interviews, resident rooms are cleaned once per week and those who receive laundry services have their laundry cleaned once per week. Additional laundry services are provided, if needed, and caregivers are instructed to clean when housekeeping is unavailable. Staff do not meet a resident's incontinence needs – Complaint alleges that resident’s incontinence needs are not being met including but not limited to not changing resident in the morning, not putting incontinence briefs on resident and not assisting them to the restroom. Staff interviews indicate that resident prefers to sleep late in the mornings and refuses to allow staff to change them or assist them to the restroom. Staff indicated that they did put incontinence briefs on resident and laundered them 2-3 times per week to reduce odor in resident’s apartment. Resident sustained a fall while in care – Complaint alleges that resident fell while in care and LPA confirmed through a facility self-report that resident did have a fall and was sent to the hospital. Review of resident’s care plan did not indicate that resident required one-to-one supervision. Resident's laundry needs are not being met – Complaint alleges that resident’s laundry was not being done frequently enough to ensure that resident’s clothes and linens remained free of odor. Per interview with staff, facility increased laundry from once per week to twice per week to assist in reducing the smell of urine. Additionally, Administrator indicated that staff were instructed to do resident’s laundry as often as was needed to ensure resident’s room was free of odor. Staff are not following a resident's needs and services plan – Complaint alleges that facility did not assess resident accurately upon move in. Based on review of facility’s initial resident assessment, resident R1 was deemed independent for most activities of daily living but required standby assistance when bathing and did use a walker when ambulating. Preplacement appraisal noted mobility issues and trouble walking. Resident’s doctor’s report that was completed prior to move-in indicated that resident was able to dress and groom themselves, toilet themselves and transfer independently but needed assistance with bathing. Following a fall and subsequent hospital stay, resident was reassessed and additional needs were noted in an updated care plan that included increased supervision, assistance with dressing, assistance to meals and increased reminders. Per interview with Administrator, the facility was providing for the increased care needs. A finding that the complaint allegations that resident is not being properly fed, staff mishandles resident's medications, facility is not being maintained in a safe and sanitary manner, resident sustained a fall while in care, staff do not meet a resident's incontinence needs, resident's laundry needs are not being met and staff are not following a resident's needs and services plan were unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred.