complaint·April 7, 2021

The investigation revealed the following: Allegation: Resident sustained multiple pressure injuries while in care. Facility staff interviewed indicated they are only aware of 1 stage II wound on R1's buttock. Facility staff indicated home health has been treating the wound and has been improving. Facility staff also indicated they have been following the care plan provided by the home health agency. A home health document dated 3/11/21 indicates a wound specialist evaluated the wound and it was diagnosed as a stage II wound on the right buttock. R1's home health nurse was interviewed. The nurse confirmed R1 only has 1 stage II wound on the right buttock. The nurse indicated he/she visits 3 times a week to treat the wound and has no concerns about R1's level of care at the facility. R1 was interviewed and he/she indicated they are comfortable at the facility. The care plan was reviewed and appears to be acceptable for the level of care R1 needs. Title 22 Regulations allows facilities to retain residents with stage I and stage II wounds as long as a detailed care plan is created by a medical professional and is followed by the facility. Based on the information obtained, the allegation is unsubstantiated. Allegation: Resident's bed is in disrepair. A virtual tour of R1's room was conducted. Facility staff assisted with adjusting the hospital bed higher and lower. The bed was working properly. Facility staff deny the bed was ever broken. Home health nurse also indicated the bed was never in disrepair. R1 indicated his/her bed has been working fine and was never broken. Based on the information obtained, the allegation is unsubstantiated. Allegation: Resident is not receiving proper nutrition at the facility. Facility staff interviewed deny the allegation. Home health nurse indicated R1's appetite has improved recently and R1 is eating more. Home health nurse indicated there hasn't been any drastic changes in R1's weight and has no concerns over R1's nutrition. R1 was interviewed and he/she indicated they like the food and has had no issues with eating the facility food. 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. A telephonic exit interview was conducted with Fern Key, and a hard copy was provided via email for signature.