complaint·April 28, 2025

Allegation: Resident sustained unexplained injuries while in care The details of the complaint allege that R1 was observed with bandages on both hands and did not remember what happened or was choosing not to say. LPA Felisa Shirley requested and received copies of all incident reports for April 2025. LPA Shirley observed an Unusual incident/Injury report, stating date occurred 4/18/25. Per interview with S9, R1 was agitated, had a suitcase packed and was trying to leave. LPA interviewed S2 and she stated that R1 was agitated that morning and S2 observed R1 sitting and scratching her wrist and observed that R1 was bleeding. R1’s wristed were treated and wrapped up by S9 and 911 was called and the family was notified. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, has there been any reports of a resident with unexplained injuries. Of those interviewed, 9 out of 9 staff answered no. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, have you reported any unexplained bruises to staff. Of those interviewed, 7 out of 7 answered no. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. 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 allegation is Unsubstantiated. Allegation: Staff do not meet a resident’s grooming need while in care On 4/28/25, LPA Shirley observed R1’s Physician Report dated, 9/1/23. The report stated that R1 has the capacity to groom herself. LPA Shirley reviewed R1’s Service Plan dated, 11/5/24, stating that R1is independent with grooming and would monitor for changes in condition and conduct a reappraisal as appropriate. During file review, LPA observed R1’s Comprehensive Geriatric Assessment dated, 9/14/23, which stated, always well-groomed without assistance, can cut and clean fingernails. LPA Shirley interviewed R1 and she stated that she likes her nails. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff meet residents grooming needs while in care. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, does staff meet all of your grooming needs. Of those interviewed, 5 out of 7 answered yes, 1 did not answer and 1 groom themselves. Con'd on 9099-C Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. 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 allegation is Unsubstantiated. Allegation: Staff did not timely address a resident’s change in medical condition LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff address change in medical condition in a timely manner. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, have you ever been ill and staff did not report your change in condition. Of those interviewed, 6 out of 7 answered no, and 1 did not answer. On 4/18/25, R1 had bandages on her wrist. S9 was notified by S2 and S8 that R1 was bleeding. S2 observed R1 sitting and scratching herself with her nails. R1 was treated by S9, 911 was called and the family was notified. Per S9, the paramedics rebandaged the wound with the original bandages and did not take R1. The family arrived later and took R1 to the hospital. LPA observed the unusual incident/injury report which stated in the comments area, will have a meeting with family about updated service plan. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. 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 allegation is Unsubstantiated. Regarding the allegations, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiencies were cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Resident Care Coordinator, Marcus Falanai .