complaint·April 19, 2022

Resident sustained pressure injuries while in care. - UNSUBSTANTIATED LPA Luisa Fontanilla interviewed Executive Director, one nurse, one Receptionist and 4 caregivers. LVN and caregivers interviewed state they do not recall R1 developing pressure injuries while at the facility. Staff state they were applying barrier cream on R1’s buttock, putting pillow under R1’s legs to get them elevated, check and change diaper/reposition every one-two hours. A review of R1’s Physician’s Report and medical records indicate R1 has a history of ulcer of right heel and ulcer of buttock. On 9/17/2019, R1 had an office visit with Podiatry Doctor for Ulcer of Right Heel. R1 moved to the facility on 10/28/2019. Facility not following physician's medical orders. – UNSUBSTANTIATED Reporting Party alleged staff were not following R1’s doctor order to change R1 every two hours instead of every 4 hours. On 4/12/2022, LPA L. Fontanilla interviewed caregivers and nurse. Staff interviewed state that they reposition, check/change R1’s diaper if needed at least every 1-2 hours. And that staff apply skin barrier ointment on R1’s buttocks to prevent pressure sores. Facility not observing changes in resident's health. - UNSUBSTANTIATED RP alleged that during RP’s last visit with R1 prior to lockdown, RP observed R1 shaking due to problem urinating and had to instruct staff to send R1 to the hospital. However, RP does not remember the date of the incident. Based on records reviewed, R1 complained of pain with urine on 7/31/2020. Facility notified the doctor and R1 was prescribed antibiotic for 5 days. Treatment ended on 8/10/2020. On 8/21/2020, R1 complained of burning to touch and with urination. R1’s doctor was notified and urinalysis was ordered. R1’s Physician’s Report indicate R1 is able to communicate needs. Staff not treating resident with dignity. - UNSUBSTANTIATED RP alleged that staff throw away left over foods brought for R1 by family. Based on caregiver notes dated 8/20/2020, R1 was served left over foods brought by R1’s family. Based on records reviewed and interview conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There is no deficiency noted. Exit interview was conducted and a copy of this report was provided to Executive Director.