Complaint·February 17, 2022

(continued from LIC 9099) During Course of Investigation on 05/12/2021, Investigator Douglas spoke with the Administrator and other facility staff. On 07/07/21 between 4:00 PM to 5:00 PM, Mr. Douglas spoke with additional facility staff. Interviews revealed that they observed the pressure injuries in between February and March of 2021. Due to lack of medical insurance coverage the facility was unable to obtain adequate medical treatment for R1’s pressure injuries and the conditions of the wounds were worsened. Staff indicated that R1’s pressure injuries were not healing due to R1 not eating well and R1's declining health condition. Staff admitted that on 02/21/2021 R1 was sent to the hospital due to developing Stage 3, Stage 4, and Unstageable pressure wounds. Then LPA Margaryan's review of the facility documents and hospital medical records revealed that R1 was admitted to the facility with the Unstageable pressure injuries which required assistance of a medically skilled professional. Due to the problems with R1’s medical coverage, R1 was unable to obtain required medical care. Subsequently, the conditions of the pressure injuries got worse and R1 developed prohibited health condition. While at the hospital, due to R1’s declining health conditions, the pressure injuries were not healing. R1 was discharged from the hospital on 03/12/21. Despite the knowledge of the Administrator and staff that upon R1 had pressure injuries upon discharge and required higher level of care, they accepted R1 back. R1 was re-admitted to the hospital on 05/04/2021 at which time the pressure injuries got even worse. Based on interviews and record review it was concluded that the facility admitted and retained a resident that required an assistance from the appropriately skilled medical professionals. Additionally, due to neglect in required incidental medical care R1 developed prohibited health condition while in care of the facility. Moreover, R1 was readmitted back to the facility when R1 requires higher level of care. Therefore, the allegation is SUBSTANTIATED at this time Citation issued. Appeal rights discussed and given Exit interview conducted. Copy of this report issued. (continued from LIC 9099-A) On 02/21/2021 R1 was sent to the hospital for malnutrition and pressure injuries. Upon review of facility records conducted on 05/21/2021, LPA did not observe any information to verify that R1 suffered a significant weight loss. Due to absence of supporting documents and based on the information revealed from interviews, there is an insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted. Copy of this report issued.