complaint·April 3, 2025

Citations

3 citations recorded^*CCLD

• 87405(a)(1)Type A

  Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by department review of facility records, home health care and physical therapy notes and hospital records that that facility did not seek timely medical attention for resident’s degenerating wounds on both legs as the facility continually reached out for wound care to make unscheduled visits to address wounds when staff members documented increased deterioration of resident’s wounds which posed an immediate health, safety and personal rights risk to resident in care.

• 87463(f)Type A

  Reappraisals: The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation, if any, of the appropriate licensed medical professional, and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident’s record. This requirement was not met as evidenced by review of resident’s needs and services plan upon return from skilled nursing, staff interviews and documentation in resident’s file. Per the needs and services plan, R1 was identified as only needing a standby assistance for toileting. Statements and documentation obtained indicate that R1 would frequently sit on the toilet for extended periods of time and staff were not always present to ensure resident did not sit on the toilet for extended periods of time and as a result developed the injuries to both legs. Home health documented that R1 is a max 2 personal assist for toileting which was not documented or integrated into R1’s care plan which poses and immediate health, safety or personal rights risk to residents in care.

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• 87463(g)Type A

  Reappraisals:The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. This requirement was not met as evidenced by R1’s medical records, home health and physical therapy care notes and statements obtained by the department. the facility did not ensure corresponding changes to the care and supervision for R1 as R1 was not re-evaluated for changes in condition and no changes to R1’s care plan were made despite developing and worsening wounds on R1’s legs and no intervention in care and supervision were provided to the resident to prevent wounds from developing and worsening including but not limited to timed bathroom breaks and padded toilet seats. As a result, R1 incurred serious bodily injuries which poses an immediate health, safety and personal rights risk to resident in care.

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