Inspection Reports for The Concierge

The complaint investigation focused on two residents: CR #2 who was discharged to a homeless shelter despite severe cognitive and physical impairments, resulting in risk of unsafe discharge and inability to manage self-care; and CR #1 who developed multiple pressure ulcers due to inadequate prevention and treatment, leading to immediate jeopardy and hospital transfer.

The facility failed to ensure a resident was discharged to an appropriate setting meeting his needs, resulting in discharge to a homeless shelter where he could not manage activities of daily living or medications. Additionally, the facility failed to prevent and properly treat pressure ulcers for another resident, leading to immediate jeopardy and transfer to acute care.

The complaint investigation focused on two residents: Resident #2 who left against medical advice and for whom the discharge MDS was not completed or transmitted, and Resident #3 who was incontinent and had missing urine output monitoring as ordered, leading to risk of urinary tract infections.

The facility failed to complete and transmit a discharge MDS for one discharged resident, placing residents at risk of improper discharge and lack of post-discharge services. Additionally, the facility failed to ensure appropriate catheter care and monitoring of urine output for one incontinent resident, increasing risk of infection and injury.

The facility failed to timely complete and transmit Minimum Data Set (MDS) assessments for residents, develop comprehensive care plans for residents with PICC lines, provide professional standard care for gastrostomy tube feedings, ensure scheduled showers and timely incontinent care, provide weekend activities, properly manage PICC line dressing changes, and maintain medication error rates below 5 percent.

The investigation was complaint-driven, focusing on allegations that residents were not receiving scheduled showers and personal grooming, inadequate foot care was provided, and medication administration documentation was incomplete or missing.

The facility failed to provide adequate personal grooming and scheduled showers for residents #1 and #2, resulting in risks for skin breakdown and decreased quality of life. Resident #2 also did not receive timely podiatrist care for long, thick, and deformed toenails, risking fungal infection. Additionally, the facility failed to maintain accurate medical records for Resident #7 regarding medication administration.

The complaint investigation was triggered by concerns about inadequate respiratory and tracheostomy care for Resident #81. Immediate jeopardy was identified on 02/16/2024 but was removed on 02/19/2024 after the facility implemented a plan of removal including staff training. The facility remained out of compliance at a lower severity level due to incomplete staff training.

The facility failed to provide safe and appropriate respiratory care for Resident #81, including failure to reconnect oxygen after trach removal, improper securing of the trach tie, and inadequate cleaning of the trach stoma. Staff had not been adequately trained on tracheostomy care. The facility submitted a plan of removal and provided training to staff, which led to removal of immediate jeopardy but the facility remained out of compliance at a lower severity level. Additional findings included failure to complete annual performance reviews for some nursing staff and medication administration errors involving Residents #79 and #80.

The complaint investigation revealed that Resident #1 was left unattended in the elevator on 11/1/2023 for approximately 20 minutes. Resident #1 was unable to maneuver her bariatric wheelchair or reach elevator buttons. Staff, including LVN1, failed to provide adequate supervision. Resident #1 experienced anxiety and distress but no physical injury. The facility conducted an internal investigation including interviews and video review confirming the incident.

The facility failed to ensure adequate supervision of Resident #1, who was left alone in an elevator for approximately 7 to 20 minutes, unable to operate the elevator or maneuver her wheelchair. Staff failed to monitor and assist the resident properly, causing her anxiety and distress, though no physical harm was reported.

The complaint investigation revealed that the facility failed to notify the physician of Resident #1's continued change in condition for approximately 12 hours, resulting in delayed emergency transport and hospitalization with Pneumonia, Acute Kidney Failure, and Septic Shock. An Immediate Jeopardy (IJ) was identified on 11/6/2023 and removed on 11/8/2023, but the facility remained out of compliance at a scope of Isolated and severity level of actual harm.

The facility failed to notify the physician timely of Resident #1's declining condition, resulting in delayed emergency transport and hospitalization with critical diagnoses. The facility remained out of compliance with actual harm severity due to ineffective measurement of their corrective plan.

The visit was complaint-related, triggered by reports from residents and family members about inadequate incontinent care, including delays in changing briefs and colostomy bags, leading to residents being left in soiled conditions for extended periods. The complaint was substantiated based on interviews and record reviews.

The facility failed to provide timely and appropriate incontinent care for three residents, resulting in residents being left in soiled briefs for extended periods, causing discomfort, risk of infections, and skin breakdown. Interviews with residents, family members, and staff confirmed delays in care and inadequate response to call lights. The facility's staff and administration acknowledged the standards for care but were unaware of the extent of the issues.

The complaint involved the resident's representative requesting the MAR, which was denied multiple times by the administrator due to concerns about releasing nursing staff names and signatures. The representative had medical power of attorney and wanted the MAR to understand medication administration during the resident's stay. The facility's policy requires a written, signed, and dated request to release such information.

The facility failed to provide the MAR to the resident's representative despite verbal requests, citing concerns about nurses' privacy. The representative had medical power of attorney and requested the records to know the medications administered. The facility allowed viewing the MAR on a computer screen but refused to provide a printout, offering only an order summary instead.