complaint·June 10, 2024

(cont. from 9099) Licensing Program Analyst (LPA) Tihesha Smith and Naira Margaryan conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation on 05/23/2024. Staff denied being neglectful in R1’s care. Interviews revealed that R1 was admitted to the facility with red blisters all over their body. Resident was admitted to the facility with assigned hospice services. Although the Administrator was informed that the red blisters on R1’s body are not infected and will not transfer to others, the Administrator sent R1 to the hospital. R1 returned to the facility within 2 hours per discharge records and R1 had a chronic condition: “adult rush” requiring daily treatment. The Administrator stated that R1 was in the facility for one (1) week and within that week due to discomfort, R1 went to the hospital 3 times. On 03/28/23, R’s condition was discussed with the discharge nurse at the hospital and the decision was made to transfer R1 to a Skilled Nursing Facility. A review of the facility records verified the information revealed by the staff. There was no information or evidence available during this investigation to conclude that R1 sustained multiple pressure injuries due to neglect. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. Staff did not have accurate records for resident. It was alleged that staff did not have accurate records for residents. Interview with the administrator revealed that she had all required documents for each resident. A review of the records including R1’s facility file, revealed that although the files were not organized, all required documents were present in folders designated for each resident. Due to no information available to support the allegation, therefore, based on observation and record review the allegation is UNSUBSTANTIATED at this time. Staff did not abide to the admission agreement It was alleged that credible witness observed lack of appropriate admission and discharge documentation. (Cont to 9099C) (cont from 9099A) Staff did not properly safeguard the residents’ medications It was observed that staff #1 (S1) pull out R1’s medication from the unlocked closet in R1’s room to assist R1. At the time of this visit at 2:30pm LPM Margaryan interview S1 in Armenian and she verified the information alleged by the complainant. LPM Margaryan also inspected R1’s room and S1 was able to show a storage space where she was and is currently keeping peroxide solution for R1. Based on interview and observation there is sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Resident's admission agreement has been forged while in care It was alleged that Resident's admission agreement has been forged while in care. A credible witness observed that the dates on R1’s admission agreement were forged. A review of R1’s admission agreement verified the allegation. There was information or evidence available during this investigation to conclude that Resident's admission agreement has been forged while in care therefore, based on record review and credible witness, the allegation is SUBSTANTIATED at this time. Deficiencies cited on 9099D Exit inteview conducted/copy of report given. (Cont from 9099C) The Administrator stated that she always keeps appropriate documents for all resident’s admission and discharge.She indicated that she is not only keeping admission and discharge records from the facility but also from the hospital and following doctors’ instructions and following all items outlined in the admissions agreements. A review of facility records verified the information received from the Administrator. Due to no information available to support the allegation, therefore, based on observation and record review the allegation is UNSUBSTANTIATED at this time. Exit interview conducted/Copy of report given.