Complaint·April 21, 2022

which continued to be treated at the facility. On 3/16/22, LPA Mknelly interviewed the Executive Director (ED). In the interview, ED acknowledged that she became aware that R1 was retained in the facility with a Stage III pressure injury. In ED’s statement, they became aware when reviewing notes while the facility nurse was absent. Reported by ED, RN was unaware that Stage III pressure injuries are a prohibited condition. While it is documented that R1 experienced pressure injuries that pressure injuries that worsened during the time noted, LPA did not find that the worsening condition from 11/23-12/17/21 was due to a lack of care. The investigation also found that in photographs provided to LPA from a party who was present at the facility, that on 1/6/22, 11:21 AM, 2/2/22 at 10:58 am, and 2/6/22 at 11:13 am, the exit adjacent to room 208 from Reminiscence was blocked by a loveseat. LPA conducted an interview (4/5/22) with a staff who recently quit working at the facility who stated that the use of furniture to block wandering residents from attempting to exit while staffing was low happened “all the time” and they suggested LPA conduct a weekend visit during the NOC shift as it continues. LPA interviewed other staff who had worked NOC shift or AM shifts who denied knowledge to this practice. The overnight staff who worked the shifts preceding the photographs did not respond to two LPA attempted phone interviews. Photographs and a supporting statement met the preponderance of evidence. 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 ED . Copy of this report and appeal rights provided.