complaint·November 26, 2024

CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility retained a resident with a prohibited health condition , the following has been concluded: Resident R1 is no longer admitted to the facility on the day of the visit and is stated to have been discharged on November 18, 2024. However based on staff interviews conducted along with a review of the resident's records maintained at the facility including the admission agreement, individual facesheet and individual needs and services assessment, R1 has lived at the facility from January 12, 2024 until their discharge in November of the same year. Records reviewed including the resident's physician report clearly indicate that the resident had a gastrostomy tube present upon their admission until their discharge. Based on staff statement, R1 was receiving home health services but was not on hospice during their period of admission. The allegation is therefore Substantiated, meaning that the preponderance of evidence threshold has been met. Regarding the allegation that Facility did not submit a written exception request for resident with a prohibited health condition , the following has been concluded: Facility staff confirms that no request for an exception was submitted. Identically, R1 was never admitted onto hospice and only had home health during their admission. The allegation is therefore Substantiated, meaning that the preponderance of evidence threshold has been met. Regarding the allegation that F acility used postural supports to limit the use of a resident's hands and feet , the following has been concluded: Based on interviews and records reviewed, resident R1 had an order for postural support via half-length bed rails to be provided. Resident was not admitted onto hospice care during the period of admission at the facility. However, based on evidence provided during the investigation, facility staff eventually installed full-length bed rails in spite of the orders and hospice status of the resident. Additionally, the bed sheets were observed to have been tied to the rails, further impeding on the ability of the resident to reposition themselves as needed. As a result, the allegation is also Substantiated, meaning that the preponderance of evidence threshold has been met. Three type A citations are issued to the facility on attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative. CONTINUED FROM FORM LIC9099-A Regarding the allegation that Facility staff are not properly trained , the following has been concluded: During the facility visit, LPA reviewed staff files for three care staff members, including but not limited to their current training transcripts which meet the requirements for the duration of initial and annual training along with the variety of topics covered which include postural supports, medication administration and dementia management. Regarding the management of R1's g-tube feeding, one staff member is verified to have current licensure as an LVN. Interviews conducted corroborated the fact that the staff member in question provided training to other care staff. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.