On 7/12/21 at 3:59 pm, LPA spoke with the Administrator who informs LPA that a family member of a resident complained to her about their mother “sitting in her bowel movement for hours.” Administrator says that “a med-tech spoke with the daughter in the past about how long it takes for resident to eat stating it takes her 45 to 120 minutes, then she goes to the bathroom every day at 12:00 pm and 1:30 pm or 2:00 pm, and sometimes she has a bowel movement at the dining table during a meal.” Administrator states that staff brought the resident back after lunch and she had a bowel movement.

On 9/22/22 at 1:45 pm, LPA reviewed administrator notes on the resident situation. In the notes, administrator writes “Checked into resident sitting in feces, watched video surveillance, found that it took her an hour and forty-five minutes to complete lunch, she was toileted right before and right after lunch…I served lunch that day and lunch the following day and witnessed it myself.” - Continued on 9099-C.

Based on the evidence obtained, the allegation “Resident left in soiled clothing for extended period of time,” is deemed Unsubstantiated at this time. Interviews and record review indicate residents’ toileting needs are being met in a timely manner.

On the allegation “Residents do not receive appropriate assistance with their medication,” the complainant’s concern was that there is only one med-tech and the med-tech does not stay in the resident’s room to ensure they take their medication. Complainant says there have been pills found on the floor of residents’ rooms. LPA investigated by interviewing the administrator, staff, and witnesses, and making observations.

On 9/27/22 at 12:00 pm, LPA interviewed the administrator. Administrator says there are two med-techs and one caregiver who are trained on medication dispensing and provided training documentation to LPA.

Based on the evidence obtained, the allegation, “Residents do not receive appropriate assistance with their medication,” is deemed Unsubstantiated at this time. There is no evidence that residents are not receiving their medications nor that there are pills left on the floor.

On the allegation “Staff are not properly feeding the residents while in care,” the complainant’s concern was that residents are “overfed and Resident #2 has gained a lot of unhealthy weight.” To investigate, LPA interviewed witnesses and reviewed records.

On 9/19/22 at 2:27 pm, LPA spoke Witness #2 (W2). W2 says that R2 “likes the food, thinks it is good quality, good portions, and good desserts and R2 likes sweets.” W2 says they have “No concerns about R2 gaining any weight” and states that R2 went through a big bag of Werther’s candy that family provided.

On 9/20/22 at 8:20 am, LPA interviewed Witness #3 (W3). W3 reports that the family member they visit is a diabetic, and staff cater to her dietary needs by giving her sugar-free syrup on her pancakes and not giving her large portions of food and minimal fruit. W3 says that she enjoys their cooks and the food they serve.

Based on the evidence obtained, the allegation “Staff are not properly feeding the residents while in care,” is deemed Unsubstantiated at this time. Interviews and records reveal that residents are getting an adequate daily food intake, and diets are specialized when needed.

Continued on 9099-C.

On the allegation, “Staff lock resident's wheelchair wheels,” the complainant’s concern was that staff lock residents’ wheels and specifically the wheels of Resident #3 (R3). To investigate the allegation, LPA interviewed staff and witnesses and made observations.

On 9/22/22 at 12:45 pm, LPA interviewed the administrator. Administrator says that “staff lock wheels of all residents for safety, i.e. at the dining table.” She says “some non-memory care residents are able to unlock their own wheels.”

On 9/27/22 between 11:47 am and 12:20 pm, LPA interviewed two staff. Staff say they only lock a resident’s wheelchair when performing a transfer and have observed other staff locking residents’ wheelchairs only for safety purposes. - Continued on 9099-C.

On the allegation “Staff do not have appropriate training to care for residents,” the complainant was concerned that staff do not have experience and do not receive proper training before caring for the residents. To investigate, LPA interviewed the administrator, staff and witnesses and reviewed records.

On 9/17/22 between 2:59 pm and 5:01 pm, LPA interviewed two witnesses. One witness explains that the resident they visited had very high standards and that they felt staff were “less trained and didn’t know how to make beds, clean rooms, and shower residents.” The other witness says they had no issues with staff being competent.

On 9/19/22 between 11:19 am and 2:27 pm, LPA interviewed three witnesses. Witnesses say the staff “have good training,” that “staff are quite good,” and “they’re fine, good staff.” On 9/20/22 at 8:20 am, LPA interviewed W3. W3 says they watch staff check on the resident they visit, take their blood sugar, and other interactions and W3 has no concerns about staff being trained.

Based on the evidence obtained, the allegation “Staff do not have appropriate training to care for residents,” is deemed Unsubstantiated at this time. Interviews and records review indicate that staff have required training to meet the basic needs of residents in care.

On 9/22/22 at 12:45 pm, Administrator says that staff “use Sani wipes to clean residents’ buttocks and sometimes use cloth towels.” On 9/27/22 at 11:30 am, S2 also states that staff use sanitary wipes and occasionally use cloth towels to wipe residents’ buttocks.

On 9/27/22 at 11:30 am, LPA toured the laundry room. LPA observed five bath towels, ten face towels, and five sheets. LPA sampled the linens and did not find significant issues with the linen. There were a few towels that were a bit ragged on the edges with minor stains but appeared to be in good shape. LPA advised administrator on replacing these soon. Administrator says she replaces them “all the time” and will take a look again to see what needs replacing.

On 9/27/22 between 11:47 am and 12:29 pm, LPA interviewed two staff. Staff say they inform S2 when linens need replacing.

Based on the evidence obtained, the allegation, “Staff use common wash cloths to clean residents,” is deemed Unsubstantiated at this time. Interviews and observations indicate that residents in care are receiving healthful accommodations.

Exit interview conducted and the report emailed to the administrator.