Complaint Investigation Report

2024. Needs and Services Plan noted R1 had Moderate toileting needs and required stand-by assistance for toileting tasks.

The hospice nurse documented on January 3, 2025 that resident was incontinent with a strong urine odor. Antibiotics were prescribed for a Urinary Tract Infection. On January 5, 2025 the Needs and Services Plan was updated by the Health and Wellness Director (HWD). Toileting needs changed from Moderate to Extensive, stating R1 required hands-on assistance from one person and the resident is incontinent. HWD spoke with hospice and family that a personal caregiver would help with R1s behaviors.

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 th at 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.