complaint·July 22, 2024

(Continuation of LIC9099) LPA attempted to redirect the conversation, but the resident was forgetful and would continuously change the conversation. Staff interviews confirmed that resident would unconsciously make-up stories and would believe that they were true. Staff said they would have to intervene and inform resident that everything would be fine so the residents emotional state would stabilize. LPA attempted to speak with the LTCO but was unable. Interview with outside source said they had no concerns with the staff, or the care being provided by the facility to their loved one. A review of records revealed that resident does have a diagnosis of loss of intellectual functioning. Their primary diagnosis on their Physician’s Report (LIC602), per WebMD’s definition, describes it as damage or disease that affects the brain that leads to an altered mental state, leaving a person confused and not acting like oneself. Their LIC602 does confirm that resident is confused and at times may not be able to follow instructions. R1 does not have the capacity to provide themselves self-care. Per their mental cognition, the resident is non-ambulatory. The resident care notes shows that the resident is in need of ADL assistance with preparing items for them and standby assist. They also require reminders. A review of incident reports (IR) revealed that resident does have a history of falls. On 4/15/24, resident was found confused on the floor and staff initiated emergency response. Resident was taken to the hospital and treated. Residents responsible party (RP) and primary care physician (PCP) were notified. Another IR, dated 01/10/2024, revealed that R1 had fallen, and emergency response was initiated and R1 was taken to the hospital to be treated. This incident caused R1 to fracture their left wrist. R1’s PCP and RP were notified of the incident. According to hospital notes, R1 had old, healed fractures to the wrist and swelling to the right knee. Their mental cognition raced from topic to topic and very disjointed thinking. R1 does use a walker and hospital staff would need to follow them closely with a wheelchair. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff, resident and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Jay Agustine. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Agustine at the conclusion of the visit. The signature below confirms the receipt of these documents.