complaint·October 10, 2023

Previous staff interviews acknowledge witnessing S1 provide insulin injections prior to obtaining their license. Interviews from previous and current staff acknowledged that R1 needed assistance with bathing, dressing, grooming, and incontinence care. Interviews stated that R1’s was incontinent of bladder and bowel. Staff stated that, for most of R1’s stay at the facility, R1’s POA refused to provide proper incontinence products for R1. Therefore, when R1 would become incontinent, this required a change of clothing. Additionally, staff stated that it was difficult for R1 to comply with incontinence care. Nursing notes also detail R1’s refusal for showers. Interviews and nursing notes detail repeated times where R1 was observed walking without their walker. Nursing notes also detail staff attempts to have R1 use their walker. Nursing notes also detailed R1 would refuse to use their glasses or leave them in other resident apartments. R1’s physicians report indicated that they had motor impairment/paralysis and needed to use a walker to prevent falls. Additionally, R1 had a history of seizures which led to additional falls. Therefore, due to R1’s history of seizures and falls, along with wandering behavior, the facility failed to provide proper supervision. Additionally, R1’s care plan was not updated as required based on level of care. Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. LPA reviewed R1’s MARs. Additionally, based on staff interviews and documentation review, LPA learned that R1 would often refuse medication. LPA reviewed communication between the facility and R1's primary physician. Nursing notes stated that R1 would become aggressive and refuse to take their medication. LPA interviewed previous and current staff who stated that R1’s had a history of agitation and being aggressive. R1 would constantly walk the hallways of the facility. LPA reviewed R1’s nursing notes which detail, at times, R1 was exit seeking. R1 had a history of going in other resident apartments and taking their items. No staff interviews revealed that R1 was being harassed by another resident. R1 had several roommates while living at the facility. Interviews acknowledged that, due to cognitive impairment of the residents, R1 and their roommate would create messes in the room. Staff stated that they tried to keep resident items organized and belongings separated. Staff interviews stated that throughout R1’s stay at the facility, there were times when the facility was short of staff due to call-ins. LPA was unable to obtain staffing schedules due to the amount of time that had passed and management turnover. Staff interviews stated that R1 was offered hydration at meals, and in between meals. Additionally, R1 had a hydration bottle. Per staff interviews, R1 would often leave the hydration bottle while walking the hallways, pour the water out, or refuse to drink. Interviews stated that R1 was constantly walking the hallways. At times, it was difficult to get R1 to sit. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. A copy of this report was emailed to the Administrator.