complaint·November 13, 2023

LPA’s interview with Administrator Nithi Narasappa and staff (S1) revealed, in the memory care units, residents who are able to go in and out of their rooms on their own do not have their doors locked when they are in them. Residents who are in wheelchairs and unable to get up on their own have their doors locked when they are in their rooms so other residents who have challenging behaviors do not go into these residents’ rooms or interrupt them and only have to push the door handle down to open if resident is inside. LPA observed locking system on door to ensure any resident that has the capability of leaving, through door, which can be freely opened by any resident residing in the room. Interview on 11/6/2023 with senior general manager revealed facility policy in memory care is to conduct continuous 2-hour room checks on the residents who are in/use wheelchairs and are behind locked doors. Based on LPAs observations, record review, and confidential interviews (8/15/2023, 10/26/2023 & 11/6/2023) with staff, outside individuals, and information received from administrator, LPA was unable to either prove or disprove staff were locking residents in their rooms with the intent of resident not to be able to exit on their own will. Therefore, this allegation is Unsubstantiated . Resident care needs are not met resulting in pressure injuries - Complainant alleges another individual informed there are unknown pressure sores on a resident. LPA conducted record review and interviews with outside parties, staff, and medical professionals that revealed R1 was seen by an outside medical professional (Hospice Nurse) since December 2022 and informed in July 2023 R1 had pressure injuries to both heals. LPA’s interviews with staff confirmed knowledge of R1’s care plan and it appears care plan is being followed. In August 2023 a pressure injury to the buttocks was noted on R1 and with staff following doctors’ orders is almost healed. Interviews with Medical professional did not reveal concerns regarding R1’s care needs are not being met. Progress notes for R1 indicates same findings as interviews. Based on LPAs observations, record review, and confidential interviews with staff, outside individuals, and medical professionals, LPA was unable to either prove or disprove resident care needs were not met resulting in pressure injuries. Therefore, this allegation is Unsubstantiated. Although the allegations above 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 allegations are Unsubstantiated .