By Shereen Siewert
A Weston assisted living facility plagued by multiple complaints over a three-year span is voluntarily closing its doors, after a state order to revoke the institution’s license was rescinded.
The state on Jan. 19 ordered Tender Reflections to stop admitting new patients and begin a relocation plan, terminating the facility’s license to operate. But Sue Te Stroete, operations support spokeswoman for Tender Reflections in Weston said the revocation order was dismissed after the organization and state health “officials came to an agreement.”
“We decided on our own to close and (the state) removed the threat of revocation,” Te Stroete said. That decision was made in early June.
Te Strote said the closing decision was based on financial hardships due to the COVID-19 pandemic and difficulty finding workers at the facility. But state documents show an array of complaints lodged against Tender Reflections, which is licensed to serve up to 80 residents, since 2018. The organization’s licensing, which started in 2014, allows for clients who are developmentally disabled, have traumatic brain injury, mental illness, advanced age, irreversible dementia or are terminally ill.
Between 2018 and 2020, state health officials conducted 10 complaint investigation surveys, according to Department of Health Services records. Multiple complaints alleged Tender Reflections “falsified, omitted or altered records,” a concern that was substantiated, health officials said.
A resident care coordinator, who was not named in state documents, told investigators he or she had been directed to exclude words like “neglect” or other information from charts and would later see comments deleted or changed. The coordinator said changes were made to avoid having the state “look at it wrong,” investigators said.
A 95-page Dec. 2, 2020 DHS report detailed allegations against Tender Reflections that included a June incident in which a resident with demonstrated “exit-seeking behavior” went to an unoccupied room and escaped through an unlocked window without detection. The resident was found by Wausau Police roughly five miles away from the facility in temperatures topping 80 degrees, the report states. Additional reports detail unwitnessed falls and injuries, medication errors and omissions and delays in mandated reporting.
Community Based Residential Facility is required to send a written report to DHS within three working days after an accident resulting in serious injury requiring either an emergency room visit or hospital admission. But after one resident had two falls that resulted in emergency room treatment between August and October, that rule was not followed, state officials said.
A Tender Reflections employee, who spoke to Wausau Pilot & Review on the condition of anonymity, said she saw at least two residents hospitalized due at least indirectly to medication mistakes, an allegation supported by state documents.
“Employees aren’t as attentive to (the) health and physical well-being of residents as they should be,” the employee said. “It’s been hard to watch.”
Other violations were noted in the reports, from lack of standard hand-washing procedures in some instances to a failure to safeguard residents from environmental hazards. Some residents didn’t receive medications as prescribed, while staff did not complete minimum training, the reports state.
So far, Tender Reflections has not relocated any of its 18 residents, Te Strote said.
“We have no idea how long the process will take,” she said. “We want to be sure to move slowly and methodically to make sure our residents find good, caring homes.”
State health officials did not immediately return a call seeking comment on Tuesday.