Complaint Investigation Report

The allegation of staff did not ensure resident’s medical needs were met in a timely manner

On 09/09/2024 Administrator, Toni Cutshall (S2) noticed that Resident 1’s (R1) finger was red and swollen. R1 was taken to St. Mary’s Urgent Care on 09/09/2024, prescribed antibiotics and was sent home with instructions to the staff to return if the condition changed. On 09/10/2024 staff observed R1’s finger had a change in color, was more swollen and staff took R1 to St. Mary’s Emergency Room.

Staff and the relatives of R1 stated that R1 had a habit of biting their fingers due to dental issues. When staff observed R1’s finger to be red and swollen, R1 was taken to urgent care, the following day to the emergency room as instructed. Therefore, this allegation is UNSUBSTANTIATED

The allegation that staff did not provide meals to resident in care

On 12/16/2024 during the initial complaint investigation, LPA observed a fully stocked pantry, refrigerator and freezer with snacks, a variety of perishables and non-perishable food items. S2 stated that the facility shops weekly for groceries and that R1 had always been a good eater. When R1 returned to the facility on 11/27/2024, staff observed that R1 did not have an appetite and refused to eat. Staff continued to offer R1 water, chicken broth, snacks, breakfast, lunch and dinner but R1 did not want to eat. Staff documented in the facility’s care notes that R1 did not eat lunch at the SNF earlier that day. Therefore, this allegation is UNSUBSTANTIATED.

The allegation that staff did not ensure resident in care was kept hydrated

On 12/16/2024 during the initial complaint investigation, LPA observed an operational water filtration device on the facility’s refrigerator, an adequate amount of bottled water and an assortment of refillable water bottles in the kitchen cabinet. On 11/26/2024 S2 visited R1 at the SNF and noted in R1’s care notes that R1’s lips appeared to be dry. When R1 returned to the facility on 11/27/2024 staff repeatedly offered R1 water, Ensure and chicken broth and R1 drank very little or would refuse. Therefore, this allegation is UNSUBSTANTIATED.

An UNSUBSTANTIATED complaint finding is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted where this report LIC9099 and LIC9099C were discussed and copy provided to Administrator, Toni Cutshall.