The Hospice Nursing Assessment/Plan of Care & Physician Orders indicates that a Hospice Nurse is to visit R1 twice a week, while the Hospice Aide will visit R1 two to three (2-3) times a week. The documented Hospice Aide Care Plan/Visit Notes indicate that the frequency that R1 should be turned and positioned for comfort/transferred is weekly/once a day including three (3) times weekly by the Home Hospice Agency. All Hospice Change in Condition/Care Plan Update/Physician Orders from 2023 do not mention any increase in transfer/turn and position for comfort. Continued on 9099-C

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Facility is not maintained in a clean and sanitary condition. It is alleged that the main bathroom in the memory care portion of the facility, off the dining room for residents, is dirty and the trash can does not get emptied out. RP also alleged that the memory care portion of the facility smells like urine, as do resident bedrooms.

On 05/25/2023, LPA conducted an initial complaint investigation visit to the facility above. LPA conducted further complaint investigation visits on 08/31/2023, and 10/31/2023. Additionally, on 10/04/2023, LPA conducted an annual required site inspection at the facility above. On 05/25/2023, LPA overheard two (2) staff members speaking about how the facility had until recently a smell in the bathroom and hallway area of the memory care portion of the facility. During the 05/25/2023 complaint investigation visit, LPA did not personally observe any smells aside from an observable smell of fresh paint. The LPA also observed new construction/repairs being done to the interior of the facility. During the initial complaint visit on 05/25/2023, the LPA observed that the facility was in the process of being cleaned by multiple staff members including the dining room, bathrooms, and hallway areas. During all other visits to the facility by the LPA on 08/31/2023, 10/04/2023, and 10/31/2023 the facility was maintained in a clean and sanitary condition as observed by the LPA. During every visit to the facility by the LPA, it was observed that all trash cans were emptied out by Staff and no common area or resident bedroom smelled of anything resembling urine.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Continued on 9099-C

On 05/27/2023, Licensing received an Incident Report with attached SOC341 from 05/20/2023. The incident report states on 05/20/2023 at 9:30am, R2 entered the bedroom of R1. R1 was laying on their bed. R2 grabbed R1’s shoulders and shook them, reportedly trying to get R1 out of bed. R2 was yelling at R1 in Spanish and told R1 they needed to get out of R2’s house. R2 shouted at a housekeeper that R1 needed to be in church and not laying in bed. Housekeeper redirected R2 and immediately notified R1’s hospice nurse, who was present in the facility, of the incident. No injuries were observed. The incident report states both residents were placed on alert charting and monitored closely, and R2 saw their physician on 5/25/2023 and their care plan was reviewed. Since that date, there have been no further incidents involving R2 at the facility.

On 10/31/2023, LPA received documentation relating to the behaviors of R2 and the supervision of R2 by facility Staff. LPA received Resident Behavior Monitoring charts for R2 for the months of April, May, June, and July of 2023. LPA received daily/weekly narrative charting regarding Staff supervision of R2 from April through July 2023. LPA received documentation of physician communication for R2 including the documented reasons for physician contact. LPA received documentation of Physician’s visits for R2 on 01/12/2023, 05/25/2023, 07/16/2023, 07/19/2023, 07/22/2023, 08/04/2023, 08/17/2023, and 08/21/2023. Physician’s Orders for R2 indicate that due to R2’s negative behaviors toward others, scheduled medications were prescribed to assist with the agitation and aggression of R2. The Physician Orders further prescribed R2 PRN medication to be given as needed. Doses of the scheduled medications and the PRN medications were increased periodically in conjunction with observation and Physician Visits. LPA received Preplacement Appraisal Information and multiple Needs and Services Plans (ANS) for R2 dated 04/13/2022, 12/22/2022, and 05/25/2023. R2’s ANS/Care Plan was reviewed and modified on 05/25/2023 to include Goals/Interventions for Agitation/Aggressiveness. Aside from the modification in medication for R2, Staff will increase supervision including daily narrative charting of R2’s behaviors.

Continued on 9099-C

LPA reviewed documentation and conducted interviews that revealed R1 was checked every 2 hours. R1 did not have a one-on-one staff and could be alone in their room. Additionally, R1 was also visited by hospice personnel about 5 times per week.

LPA reviewed an incident report for R3. On 5/6/2023 at 10:50am, R3 was sitting on a bench in the memory care hallway. A housekeeper walked by R3, and a few seconds later, heard a loud sound. The housekeeper checked and found the resident laying on their side with a bump on the middle of their forehead. 9-1-1 was called and the resident was assessed at the emergency room. R3 returned to the facility afterward. There was no evidence to suggest that R3 was not properly supervised during this incident.

The facility acted promptly and appropriately in addressing the behavioral issues of R2 after the incident on 05/20/2023 with R1. Through the review/modification of R2’s ANS/Care Plan as well as the continued Physician Appointments for medication management, R2 has decreased in behaviors that could be harmful to the safety of other residents in care. LPA visited the facility on 05/25/2023, 08/31/2023, 10/31/2023 and 11/14/2023 for complaint investigations. LPA additionally visited the facility on 10/04/2023 for an annual facility site inspection. At each facility site visit, the LPA did not observe any Staff members sitting on a couch, talking/going through cell phones, or neglecting walking through the facility supervising residents in care. LPA interviewed residents in care including R1 and R2, and Staff members of the facility. individuals interviewed stated that supervision was adequate at the facility. Interviews with the LPA indicated that the facility had previously lost members of the Staff within the last few years due to the COVID-19 pandemic, but that the facility has sufficient staff competent to provide the services necessary including supervision of all residents in care.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of this report provided to the facility.