complaint·October 24, 2023

CONTINUED FROM FORM LIC9099-A Regarding the allegation that Residents sustained bed sores due to neglect , the following has been concluded: Based on a review of medical records which include four separate physical examinations performed by multiple attending physicians on June 7, June 16, June 17 and June 18, 2023, there was no noted presence of pressure injuries that would have been sustained by R1 during their admission at the facility. As a result, the allegation is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff failed to meet resident's medical needs , the following has been concluded: Based on interviews and records reviewed, resident R1's condition started declining due to the onset of pneumonia. Hospital records reviewed did not point out any new or worsening health condition which could be attributable to inadequate care. Each instance of concern about the resident's health was addressed by a referral to the paramedics and transport to the hospital. A failure to meet R1's medical needs can therefore not be evidenced. The allegation is therefore found to be unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did occur. Regarding the allegation that Resident sustained multiple falls due to neglect , the following has been concluded: A review of available records evidenced two separate unwitnessed falls occurring on June 6 and June 17, 2023. In both instances, paramedics were activated for evaluation and R1 was transported to the Emergency Department for evaluation and wound care as is required by Title 22 regulations. Facility additionally reported the hospital visits to the Department. However the evidence gathered cannot establish a direct relation between the falls and inadequate care and supervision by facility staff. Shortly after the second fall, the resident was diagnosed with sepsis related by a respiratory infection which may also have contributed to the occurrence of the fall. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did occur. An exit interview was conducted and a copy of the present report was provided to a facility representative.