Facility Evaluation Report

This report is being amended to include required information that was omitted by LPA in order to meet department standards of required information including who LPA met with during the inspection.

Licensing Program Analyst (LPA) Kevin Gould made an unannounced Case Management inspection to the Eskaton Gold River Lodge (RCFE) on 11/16/23 at 9:00am to address concerns observed during a complaint investigation. LPA met with Lynn Perena and together discussed the department’s concerns and observations.

Based on statements obtained during the department’s investigation of an assigned complaint the department has determined there is a preponderance of evidence to support multiple staff members including outside caregivers discussed or expressed concerns with a decline in resident’s cognitive abilities, short term memory and orientation of time and place. Three care providers who interacted with R1 on a regular basis provided statements to the department observing confusion and cognitive decline of R1. Two of the three interviewed described confusion related to facility orientation. Two staff members interviewed provided statements that R1’s mental decline was a topic of discussion in “stand up” meetings among staff members. The latest Physician report dated October 2022 did not include any mention of dementia or MCI. Other documentation observed post physicians report include: additional confusion, wandering and looking for 5 dogs (resident only had one at the facility). All documentation and statements were given prior to the resident care meeting with authorized representatives where memory care placement was discussed but no evaluation was conducted to ensure resident’s needs were met by facility staff.

Department interviews and review of surveillance footage with morning shift staff present on the date Resident was discovered outside the building, observed resident’s dog in the parking lot unattended at approximately 4:58am. Facility staff interview indicate facility staff were not notified by arriving staff member until 5:20am and resident was discovered outside the building at approximately 5:23am. The department has concluded the staff members present did not display competency in the required duties for care and supervision of resident as resident’s animal was observed unsupervised and resident was not checked on immediately to ensure the resident’s health and safety.