Complaint·July 22, 2024

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident sustained pressure injuries while in care. It is alleged that a resident was at this facility during the dates of 03/15/23-03/22/23 and came home with sores on their buttocks and resident is not able to fully extend their left leg. On 03/28/23 LPA Montoya interviewed S1-S3. (3) out (3) staff said that there were no residents who sustained pressure injuries while in care during the dates of 03/15/23-03/22/23. On 03/28/23 LPA Montoya interviewed R2-R4 and asked if they knew or were aware of any resident sustaining injuries while in care at the facility. (3) out of (3) residents interviewed revealed that no resident had sustained injuries while in care. On 07/22/24 LPA Elvira Gonzalez conducted an interview with Administrator Miriam Rudes and it revealed that R1 was not on hospice or home health during their stay at this facility between the dates of 03/15/23 and 03/22/23. Administrator Rudes stated that when R1 was brought to the facility they had no visible pressure injuries but appeared to be very frail and delicate. On 07/22/24 LPA Gonzalez reviewed the Appraisal/Needs and Services Plan, Physician’s Report for resident R1. Physician’s Report (dated 03/14/23) revealed that R1 requires assistance with all activities of daily living, which includes bathing, toileting, eating, drinking, and medication administration. Physician’s Report also revealed that R1 has a history of skin condition or breakdown with a note under the explanation column stating the buttocks and that R1 had a recent hip fracture. Based on interviews conducted with facility staff, facility clients, and LPA record review, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Continued on LIC9099-C Allegation: Facility staff did not follow resident's care instructions. It is alleged that this facility did not follow instructions in caring for the resident. On 03/28/23 LPA Montoya interviewed S1-S3. (3) out (3) staff said that they follow each resident’s plan of care. On 03/28/23 LPA Montoya interviewed R2-R4 and asked if staff do not follow resident’s care instructions. (3) out of (3) residents interviewed revealed that staff do follow the resident’s care instructions. On 07/22/24 LPA Elvira Gonzalez conducted an interview with Administrator Miriam Rudes and it revealed that the each resident has a plan of care written and is followed thoroughly. Miriam Rudes stated that when R1 arrived at the facility, the facility was provided with a food and beverage thickener from the family. She stated that staff at this facility did use the thickener. Miriam Rudes said that staff made sure that R1 was more than comfortable during their short stay at this facility. Based on interviews conducted with facility staff, facility clients, and LPA record review, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Allegation: Facility staff did not properly bathe resident. It is alleged that a resident was not bathed properly during their stay at this facility. On 03/28/23 LPA Montoya interviewed S1-S3. (3) out (3) staff said that they do bathe residents. On 03/28/23 LPA Montoya interviewed R2-R4 and asked if staff properly bathe residents. (3) out of (3) residents interviewed revealed that staff do properly bathe residents. On 07/22/24 LPA Elvira Gonzalez conducted an interview with Administrator Miriam Rudes and it revealed that the depending on the residents care needs is how often they are bathed. For a bedridden resident they are given a bed bath 3-4 times a week, and if the resident denies a bath, it is not forced. Based on interviews conducted with facility staff, facility clients, and LPA record review, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Based on interviews conducted with facility staff, facility clients, and LPA record review there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held. A copy of the report was provided to Caregiver, Ina Hamsiah.