Facility progress notes, beginning on December 16, 2024 report R1 was resistant to being directed to the toilet, would remove pull up and frequently urinated or had bowel movements in common areas. Facility staff worked with hospice to find ways to mitigate these behaviors. The allegation that Staff did not meet a resident’s incontinence needs is Unsubstantiated.

It was alleged that Staff did not have planned activities for the residents. LPA obtained Activities Calendar for Assisted Living (AL) and Memory Care (MC), also known as Revere, with Daily Activities detail by the hour for February and March 2025. LPA observed there were six to seven scheduled activities per day. LPA toured Revere on March 18, 2025 and observed four residents painting shamrocks that were continued from a St. Patrick’s Day activity on March 17, 2025.

LPA interviewed two of two Activities staff regarding the implementation of activities. One staff member works Sunday through Thursday and the other works Tuesday through Saturday. There are only three days where both activities staff are present. Of the three days when both are present, one staff member usually drives residents for scheduled appointments as needed. Interviews shared that if an activities staff member needs to drive, the staff member will start the activity and leave instructions for care staff to complete with residents. Four of the seven days per week there is only one activities person on-site.

(Continued on LIC 9099C1)

Due to staffing shortages activities staff were pulled to assist with non-care needs; such as serving food or answering calls. Staffing shortages were cited on May 13, 2025 Control number 22-AS-20250509094345. Thus, although activities were always planned, staffing dictated if they could be implemented. Therefore the allegation that: Staff did not have planned activities for the residents is Unsubstantiated.

It was alleged that Staff mishandled a resident’s personal belongings due to R1’s soiled clothing being thrown out. LPA interviewed two of two housekeepers who reported they are responsible for cleaning resident rooms, once per week, or as needed. Per interviews with two of two housekeepers, care staff are responsible for laundering resident personal belongings.

LPA interviewed four of four med technicians and three of three care staff. Interviews with three of three Revere care staff stated that when a resident’s clothing is soiled, most times staff discover the resident throws the clothing away in trash cans, attempts to flush soiled clothing in toilet, hides soiled clothing in furniture or places item in another resident’s room. Care staff denied tossing R1’s clothing and that staff make the effort to clean the resident and launder the clothing.

Facility progress notes on December 20, 2024 documented R1 was aggressive towards staff and another resident and was removing and taking their belongings. When staff were asked for three items of R1’s clothing that were missing, the staff member who stated the soiled clothing was thrown away denied the allegation. Thus, the allegation that: Staff mishandled a resident’s belongings is Unsubstantiated.

(Continued on LIC 9099C2)

Hospice notes dated January 8, 2025 documented that nurse reported the bruise under R1’s chin and the skin was intact. Family was notified by facility of the bruise. Med Tech was unaware of how R1 received the bruise and there were no falls reported.

The unexplained bruise was immediately identified and reported to the Health and Wellness Director, Hospice nurse and family. Thus the allegation that a resident sustained an unexplained injury while in care is Unsubstantiated.

It was alleged that Staff did not properly report incidents involving a resident. Review of facility progress notes from January 11, 2025 stated R1 had a fall in the dining area during lunch time and was witnessed by care staff. The fall happened approximately at 11:15 am and Med Tech (MT) charted at 1:37:02 pm that the spouse was called twice but MT was unable to leave a voicemail due to the voicemail box being full. On the third try MT texted information to spouse’s cell phone. Charting notes stated the daughter was also called and was unable to get a hold of her, but an incident report was made. MT also notified hospice and spoke to the nurse. MT spoke to Manager on Duty (MOD) that MT attempted to contact family.

At 12:23pm MOD left a voicemail for family to call the community. The voicemail also references other items to address with family but does not state that R1 was sent out per facility policy. R1 was transported via ambulance to a local hospital for further evaluation. On January 11, 2025 at 9:30pm progress notes stated resident moved out this evening and meds were signed out and given to family. The allegation that Staff did not properly report incidents involving a resident is Unsubstantiated.

(Continued on LIC 9099C3)

LPA conducted interviews with six of six staff who reported their priority is assisting residents who require feeding. Staff interviewed reported R1 often would remain in their bed due to being awake most of the night. Due to staffing needs, they had to first assist with residents who were present in the dining area and required feedings. Staff frequently checked on R1 and would attempt to coax R1 to eat.

Per Pre-Appraisal dated December 15, 2024 food allergies were noted, R1 does not eat lunch and eats small portions. Review of facility progress notes reported R1 often would remain in their bed during scheduled meal times. Med Tech charted on December 16, 2024 that R1 stated they were not hungry. R1 was given water and propel powder provided by family. Family was aware R1 did not always eat. Notes report on December 18, 2024 R1 refused dinner and chose to eat two cookies. On December 22, 2024 R1 ate with family member but only at three to four spoonfuls of dinner. It is noted that spouse said this was the normal eating pattern. Family stated that if R1 refuses to eat, to provide Ensure or pudding. On December 24, 2024 R1 refused to eat and spouse was made aware. On December 30, 2024 R1 ate 100 percent of dinner. On January 6, 2025 R1 ate 80 percent of dinner.

Hospice notes reviewed dated December 15, 2024, documents R1's wandering behavior, separating themselves from others; and refusing eating and medications. On December 20, 2024, Hospice notated that R1 continued to have a decline in appetite. On December 30, 2024 Hospice noted a weight loss of eight pounds. Hospice nurse met with HWD and MT to discuss ways to increase R1’s appetite.

(Continued on LIC 9099C4)

It was alleged staff did not have adequate recording keeping of a resident due to facility not documenting R1’s weight daily. Per R1’s hospice weight records reviewed, R1 was weighed on December 15, 2024, to weigh 116 lbs. R1’s physician report dated December 12, 2024 further corroborated R1’s weight at 116 lbs. LPA conducted interviews with three of three staff that facility policy is to weigh residents once per month or as prescribed by physician's order.

On December 20, 2024, R1’s hospice notated R1 continued to have a decline in appetite. On December 30, 2024, hospice weighed R1, and notated their weight to be 108 lbs, a decline of 8 lbs over a period of approximately two weeks. Facility frequently communicated with hospice regarding R1’s loss of appetite. R1 exhibited behaviors and hospice continued to try different medications to help R1 sleep through the night and help with the behaviors. R1 would often refuse to eat and spit out medication. On January 3, 2025 R1 also was diagnosed with a Urinary Tract Infection and hospice notes report resident was nauseous and felt like vomiting. Both facility and hospice monitored the food and nutrition for R1.

Interview with Executive Director stated when residents move into the community, the weight is taken from the Physician’s Report. The facility’s policy is to weigh residents monthly or as prescribed by physician's order.. R1 came to the facility on December 15, 2024 and was weighed on December 30, 2024 when concerns were relayed to hospice. Thus the allegation that staff did not have adequate record keeping of a resident is Unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations that: Staff did not meet a resident's incontinence needs, Staff did not have planned activities for the residents, Staff mishandled (Continued on LIC 9099C5)

An exit interview was conducted with Executive Director, Cynthia Figueroa and a copy of this report was provided to the facility.