complaint·June 23, 2022

On 01/03/22, staff called medical advice nurse and requested a regular home health nurse to follow up for wound management. S1 left a message with R1’s primary care physician and authorized representative for after emergency room visit. On 01/04/22, staff called 911 again because R1 had increased cough, chills and fever. Staff observed R1 started having difficulty moving around and his mobility has sharply decreased. Staff stated that they observed little blisters forming throughout his body despite all the interventions that they implemented by elevating his heels, frequent repositioning and diaper changes. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. Allegation: Resident’s care needs are not being met Investigation Finding: UNSUBSTANTIATED Based on interviews and record reviews, LPA's review of incident report dated 12/23/21 show staff observed R1 developed a fever and forming blisters on both heels. Staff called 911 on 12/30/21 and R1 was treated at the hospital and released back to the facility. Staff followed wound care instructions, treated the blisters, bandaged them and elevated R1’s legs . Staff also noticed that R1 started to develop a bed sore on his butt and contacted his primary care physician to request a home health nurse for R1. Staff stated R1 started to develop more bed sores at his hips on 01/03/22 despite staff turning him every 2 hours, assisting with his walks and hydrating him. Staff called 911 again on 01/04/22 and was taken to the hospital for evaluation and treatment. R1 was treated for fever and increasing bed sores. He was later admitted at a skilled nursing facility from the hospital. On 02/11/22, R1 returned back to the facility under hospice care. Other residents at the facility stated their care needs are being met by staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided via email.