Complaint·February 23, 2024

(Continued from LIC9099 p.1) Records review revealed that R1 had ongoing issues with their incontinence equipment, which resulted in R1's skin being exposed to moisture for extended periods of time, which was known to exacerbate skin breakdown. Records review showed that staff monitored R1's skin condition daily and elevated the issue to R1's physician, Responsible Party, and Home Health agency. Outside source interview did not corroborate the allegation, informing that they had no knowledge of the accusation or issue at the facility. R1 was unable to be interviewed for the investigation. Regarding the allegation, "Facility did not maintain resident's room temperature within regulation", it was alleged that the Licensee did not act when R1's room was observed to be of high temperature. Staff interview revealed that R1's Responsible Party would regularly increase the temperature of R1's room by turning on the room heater plus an additional personal heater, and place extra blankets on top of R1. Staff interview further revealed that staff attempted to turn off the heaters and remove the blankets, and open the windows in R1's room to cool it down. Staff interview further revealed that staff observed R1 to show signs of being too hot, such as visibly sweating, and communicated to R1's Responsible Party that R1 was too hot. Additional staff interviews revealed that on hot days staff would open windows and corridors throughout the facility for airflow, maintaining a comfortable temperature. Outside source interview revealed observations of staff placing a fan in R1's room to lower the temperature. Additional outside source interviews did not corroborate the allegation, informing no knowledge of the accusation or issue at the facility. Review of temperature records on the day in question produced varied results. Almanac.com showed that the temperature range on the day in question was between 66.9 and 97.0 degrees Fahrenheit; farmersalmanac.com showed a temperature range between 68.0 and 88.9 degrees Fahrenheit. No records were found to confirm the temperature of R1's room the day in question. As such, no evidence was found to corroborate that the Licensee did not maintain R1's room within regulation. No records were found to indicate that the facility exists in an extreme temperature area. (Continued on LIC9099 p.3) (Continued from LIC9099 p.2) During an unannounced facility visit, LPA directly observed R1's former room, which was on the first floor of the building. LPA's observations corroborated staff statements regarding the ability to individually heat the room via heater. LPA observed windows in the room that could be opened for airflow, and also observed other resident rooms with open screen doors and/or windows for temperature preference. R1 was unable to be interviewed for the investigation. Based on interviews, direct LPA observations and records review, The investigation did not yield a preponderance of evidence to conclude that facility staff failed to position resident, and facility did not maintain resident's room temperature within regulation. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Mina Ramirez, Caregiving Supervisor, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.