Hidden Glenn Senior Living VII

Allegation investigated: Staff are not meeting resident's dietary needs.

On 08/20/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation listed above. The LPA met with Brigitta Lofvendahl, Executive Director and explained the elements of the allegation. The investigation consisted of interviews and records review. On 08/11/25 Community Care Licensing received a complaint alleging staff are not meeting resident's dietary needs. It was alleged that Resident #1 (R1)s dietary needs are not being met. It was further alleged that R1 is not allowed to have too much meat, there are no alternate meals, and that R1 is buying their own food. During today's visit, LPA conducted a review of the facility food supply, which was found to be adequate as there was a 2 day supply of perishables and a 7 day supply of non perishable food items. LPA conducted a records review and R1 was not observed to have a prescribed modified diet from a physician. Further the physician's report dated 12/01/24, indicates that R1 does not have a special diet. Per interview conducted with R1 revealed that when it comes to the food that is being served that if they do not eat it and that they Unfounded will order their own food from fast food restaurants. R1 denied making a request to staff to be served an alternate meal. Per interview with Executive Director Brigitta Lofvendahl, R1 does not have a prescribed modified diet, but a request was received on 07/05/25, from R1s responsible party for R1 to have more vegetables when meat is being served. Per Lofvendahl the staff were informed of the request, and have followed the directive that was given. Additionally, per a records review of a unusual/injury incident report R1 was sent out on 06/07/25, for symptoms related to a medical diagnosis. The LPA reviewed emergency room discharge paperwork for R1 dated 06/07/25, and one of the instructions for care at home provided was to "eat less seafood and red meat", and to follow up with primary care physician. Per the email dated 06/13/25, R1's discharged paperwork was sent to R1s doctor. A response was received via email on 06/19/25 which included two medication prescriptions. There is nothing documented stating that R1 was prescribed a modified diet. Based on interviews and records review, the allegation of staff are not meeting resident's dietary needs, is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was reviewed and provided to Brigitta Lofevendahl, Executive Director.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 18-AS-20250820095304

Type of visit: Required - 1 Year

On today's date 07/29/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for the purpose of conducting a 1 year required visit/annual inspection. LPA met with Executive Director Brigitta Lofvendahl and explained the purpose of the visit. The facility is licensed to serve residents age 60 and over, 15 non ambulatory of which 15 may be bedridden. The facility has an approved hospice waiver for six (6). There are currently zero resident's receiving hospice services. The facility is a single story structure with 8 combined bedrooms and bathrooms, dining area, front and back patio, kitchen, living room, activities room, medication closet, and garage which is used to store the laundry appliances, generator and extra food. The facility was observed to be clean and clutter and odor free. The call lights were tested and observed to be operable. LPA observed all toxic chemicals and other hazards/sharps to be inaccessible to residents. The medications are locked inside the mediation closet, that is accessed via a key pad. The facility food supply met the requirements of a 2 day supply of perishable and a 7 day supply of non perishable food items. There are no pools or bodies of water on the premises, are known guns or ammunition. LPA conducted a file review prior to inspection and observed for there to be outstanding annual fees, during today's visit, proof was provided confirming that the fees have been paid. Based on today's inspection no deficiencies were issued. LPA conducted a records review and observed the following: Staff present were observed to have obtained criminal record clearance and to be associated to the facility. Staff present were observed to have current CPR/First Aid training, and possess a valid Administrator certificate which expires on 04/16/2025. Resident files were observed to have the required documentation such as physician's report, appraisal, and admissions agreement. The hot water temperature was tested and found to be within regulatory limits. The facility was observed to have (3) fully charged fire extinguishers fully charged. The emergency drills are conducted quarterly, the last drill was conducted on 4/16/24. Based on today's inspection no deficiencies were issued. An exit interview was conducted and a copy of this report was provided Executive Director,Brigitta Lofvendahl.the state’s words, verbatim · CDSS document, Jul 29, 2024

Allegation investigated: Staff chemically restrained resident Licensee did not report changes in resident's medical condition to resident's physician Licensee did not report changes in resident's medical condition to resident's responsible person

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the investigation. LPA met with Executive Director, Brigitta Lofvendahl. During the investigation, interviews were conducted along with record review. It was alleged staff chemically restrained Resident #1 (R1) and didn’t report R1’s change in condition to their responsible party and physician. It was reported R1 was sedated and falling asleep while walking to lunch. The sedated condition was being reported as a result of a medication named Haldol, which was prescribed by R1’s physician. R1’s Physician’s Report dated 02/27/20 indicated R1 had a Major Neurocognitive Disorder and was non-ambulatory, with the use of a walker. It also indicated R1 had aggressive behavior, and was able to feed themselves only, not able to handle any other activities of daily living. A review of the Facility’s Progress Notes dated back to 02/05/20 from R1’s physician, noted R1 with behavioral changes, not following directions, and increased anxiety and irritability. Continued on an LIC 9099C. Unsubstantiated Physician visit dated 04/15/20 listed the chief concern as Progressive Major Neurocognitive Disorder with behavioral disturbances. That report was signed by the physician stating to monitor R1 as every visit there’s more isolation and yelling. Physician visit dated 06/25/20 noted R1 was still very agitated, yelled, and slammed doors. Facility records reflected another one of R1’s physicians wrote a prescription for Haldol on 08/17/20. Facility progress notes dated 08/18/20 reflected R1’s aggression, as R1 was seen striking another resident on their left shoulder with a closed fist. R1’s responsible party was notified and stated they were fine with medication intervention to alleviate aggression. The facility was following physician’s orders and did not note negative or sedative effects of the medication. The facility was following physician’s orders as prescribed. Staff interviews revealed they did not witness R1 appear groggy or sedated. Therefore, there were no changes to report besides the increased aggression. An outside source interview revealed R1 was falling asleep while eating. A review of R1’s medical records showed R1 was being evaluated and the physician did not state R1 appeared sedated. Staff admitted R1 would eat with their eyes closed and open them once finished. On 09/08/20, the Facility’s progress notes reflected a new order to increase Haldol. Facility progress notes dated 10/01/20 documented notification of R1’s responsible party regarding R1’s behavior and aggression towards staff, and residents. R1’s physician requested to get a psychiatrist to see the resident and stop medications Haldol and Seroquel because resident was allegedly salivating. Facility staff interviews denied R1 was salivating. Another notification was sent to R1’s responsible party on 10/02/20 indicating medication change to discontinue Haldol and was recommending another medication, the responsible party agreed. There were multiple communication notes and documentation from the facility to R1’s physician and responsible party notifying them of changes with R1. In addition, R1’s responsible party acknowledged the communication correspondences, each time they were notified of any changes with R1. Most changes were R1’s aggression towards others. On 10/22/20, R1’s responsible party documented when R1 was weaned off Haldol, R1 started yelling and getting angry whenever they had a conversation. R1 was receiving medications as prescribed and the responsible party and physician were made aware of R1’s conditions, which was why the physicians were adjusting R1’s medications. A review of R1’s medical records and interviews indicated the facility was in constant communication with R1’s responsible party and physician. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Brigitta Lofvendahl whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 20, 2024 · control 08-AS-20201008080656