complaint·April 19, 2023

Resident file reviews found that: Facility had only a Physician’s report dated 1/28/15. Statements from the licensee found that that 1/28/15 report was from R1’s prior placement and a new report was not obtained for within 12 months of R1’s admission to this facility. Furthermore, the 2015 physician’s report stated that, “will need to find a primary care physician in the community.” Also on file was R1’s Identification and Emergency Information dated 11/29/15 which listed a physician who had previously treated R1 but had retired. During R1’s stay at the facility, the licensee did not assist R1 with obtaining a primary care physician. 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 licensee . Copy of this report and appeal rights provided. Staff does not ensure resident is taking prescribed medications- As R1 did not have a primary care physician while a resident at this facility, R1 also had no prescribed medication. Statements from the licensee and staff were that in 2014-2015 R1 was prescribed medications for agitation and anxiety. Statements also were that as R1 adjusted to the facility that he was in at the time, those medications were discontinued. R1 was admitted to this facility with no medications nor medication orders. Resident fell while in care- R1 was noted in records to have a fall history. On 9/24/22, R1 had a recorded fall for which R1 was transported to an area hospital for evaluation. Statements provided did not find that the fall occurred due to staff actions or inactions. Staff did not ensure resident is being repositioned- While R1 has significant motor disfunction and left hemi-paresis, R1 was able to reposition independently. Records did not indicate R1 had experienced skin breakdowns while at the facility. R1’s bed was equipped with ¼ bed rails and trapeze bar. Staff did not have proper training to transfer resident- Licensee had general training on file. Other staff training was not present at the facility during inspection. Records from skilled nursing did not indicate R1 required specialized transfer. Staff did not provide resident with eviction notice- R1 was not evicted. Statements obtained were that at the time of R1’s 9/24/22 hospitalization, the licensee and R1’s power of attorney (POA) voiced concerns regarding R1’s physical decline and a need for a higher level of care. As a result, R1 was transferred to rehabilitation where he remained for the duration of this investigation. POA stated that it was his request that an alternative placement be pursued and that R1 would not return to this facility. During the course of this investigation, additional deficiencies were found and cited on a separate report. 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. Exit interview with licensee.