complaint·October 19, 2022

change resident’s soiled brief and clothes immediately after a third-party visit. Interviews with witnesses reveal that R1 is clean and dry when seen by witnesses. Resident interviews reveal that they call staff when they need toileting assistance. This allegation is unsubstantiated. Allegation 3: Staff did not administer resident's medication(s) as prescribed. Records reviewed and LPA observations revealed that medication record and medication match on dates when R1 was not in the facility. Staff and witness interviews reveal that medication is administered accordingly, sometimes with apple sauce but whole and uncrushed to aid R1 swallow the medication. Resident interviews reveal that they call staff when they are receiving their medication timely. This allegation is unsubstantiated. Allegation 4: Staff did not seek medical attention for resident in a timely manner. LPA observed staff using mobile devices and walkie talkies at work. LPA observed communication devices in use and observed nurses respond to staff request for assistance. Interviews with staff reveal that residents are sent to the hospital after nurse assessment. Resident interviews that they can contact staff when they need immediate medical assistance by pushing their pendant. This allegation is unsubstantiated. Allegation 5: Staff did not adhere to resident's care plan. Records reviewed show that R1’s care plan was updated less than 45 days ago. Interviews with staff and third party confirm that R1 hired a personal caregiver not associated to this facility less than 45 days ago. LPA observed several staff assist R1 multiple times during today’s visit. This allegation is unsubstantiated. Allegation 6: Staff do not have the adequate skills to transport resident(s) in a safe manner. LPA observed 2 staff transfer R1 manually. Witness interview shared that they observed staff to safely transfer residents. Resident interviews reveal that they feel comfortable with staff transferring them to and from their beds and chairs. This allegation is unsubstantiated. Allegation 7: Staff did not properly manage resident's incontinence care resulting in infection. LPA observed 2 staff change resident’s soiled brief and clothes immediately following a third-party visit. LPA could not find corroborating paperwork indicating that R1 developed an infection from lack of incontinence care. Resident interviews reveal that their briefs are regularly changed by staff and residents can get in touch with staff by way of their pendant necklace. This allegation is unsubstantiated. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Mrs. Crokem and a copy of this report was provided.