Complaint·May 10, 2022

possibly preventing the incident to occur on 11/26/19. Based on the information obtained, there is enough information to corroborate with the allegation of resident causing injury to another resident while in care. Therefore, the allegation is Substantiated . Citation(s) issued on the 9099D. Staff did not address a resident’s change in medical condition: In regards to the allegation, it was reported that on or around 10/30/20, R1 was treated for an edema. R1 received instructions to follow up with their primary doctor in one to two days, or to return to the emergency room if symptoms worsened. The investigation revealed that there was no follow up appointment with R1’s primary doctor. R1 wasn’t seen until 2/3/21. Between 10/30/20 to 11/26/20, there was documentation that R1 experienced swelling and redness on six different days, but no record of a hospital visit or attempts to treat R1’s condition. Additional documentation also noted that on 11/24/20, R1 had a “little open hole” to their ankle, but no notation that it was being treated. Based on the information obtained, there is enough information to corroborate with the allegation of staff not addressing R1’s change in condition. Therefore, the allegation is Substantiated. Citation(s) issued on the 9099D.