complaint·November 22, 2022

** Amended** Records reviews conducted 10/14/22 by LPA Mknelly for R1 found that R1 did not have a care plan documented. The facility only had a pre-appraisal on file. The pre-appraisal, from 11/10/21, identified R1 as experiencing Dementia with short and limited long term memory, is active with a use of a walker, occasionally needs assistance with transfers. R1’s physician report dated 11/2/21 notes Dementia with confusion and aggression at times. R1’s injuries, supervision level and strategies for her to move safely were not communicated to staff in a written care plan. Interviews with staff found that staff had a informal plan of attending to R1 (and they reported to engage with R1 often). However, the strategy by staff was to remind R1 to move safely and call for assistance as needed. R1’s poor memory was not accounted for in the plan and therefore did not address R1’s care and supervision needs. 87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Administrator . Copy of this report and appeal rights provided. ** Amended** The event of R1 found to have a medication still in their mouth following a medication time was an unusual event for that resident. LPAs observed staff to wash their hands and interview statements are that staff are disciplined in hand hygiene Residents alleged to be in soiled clothing for extended time was reported for a time when R1 was in the hospital. No additional incidents were found. Inspections found the facility odor free Staff interviews, records found notification of resident’s authorized representative of resident’s change in condition were regular and often. Interviews of residents did not support that staff do not respond to resident’s call for help Staff interviews and records reviews found that resident’s hygiene needs appear to be met. Allegations Resident sustained multiple injuries while in care and Resident sustained a fracture while in care found that R1 did, in fact, sustain injuries and a fractured wrist (3/27/22) while at the facility. However, the allegation, as written, does not attribute fault to staff care or lack of care. R1’s fracture was due a unwitnessed fall from bed as reported by R1 to staff. R1 stated that they informed staff of pain. Medical care was sought timely. R1’s other bruises and skin tears often were unwitnessed events when R1 was moving independently throughout the home. Therefore no violation is noted for these events at this time. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Report provided. On 12/6/22, LPA emailed licensee amended report to licensee for signature to be in facility file reported outbreak but one did not occur at this residence during the period alleged. This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and report provided.