complaint·October 3, 2022

Allegation: Resident(s) sustained injuries while in care at facility. During the course of investigation, records review indicated that C3 was brought to emergency room on 1/6/2022 due to chief complaint of “resident getting weaker”. Upon admission at the emergency department, records review indicated that C3 was referred to a doctor for wound evaluation for “potential or confirmed pressure injury sacrum/buttock” , records indicated that wound is closed, none serous filled blister, no odor, no edema noted, records also indicated that wound is “not pressure injury”, another hospital records indicated that C3’s right and left heel had wound, however hospital records did not indicate the stage of wound, records reveal no sign of infection, skin was dry and intact. C3 was not admitted to the hospital due to other reason. LPA was unable to prove or disapprove that administrator or facility staff neglected the clients in care. Allegation: Staff did not meet incontinence needs of residents/clients resulting to septic shock Based on interview, staff are changing diapers as needed. Interview with staff reveal that clients are check every 2-3 hours for incontinence care. Staff stated that client/s would be cleaned and sometimes showered after an accident on top of the regular showers scheduled for clients in care. Although C1, C3 & C6 was diagnosed of septic shock, there were no indication of the cause and records review did not indicate that this was due to facility failed to meet incontinence needs of the clients. Allegation: Staff yelled in front of resident(s). LPA conducted interviews with clients and staff. LPA tried to interview clients in care but the clients are non-verbal and did not respond to any of the interview questions. Staff denied yelling at the residents or clients in care and denied knowing any incident/s of yelling towards the clients. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.