Complaint·July 29, 2025

(Continued from LIC9099) (Page 2 of 3) Regarding the allegations, neglect resulting in injury and facility did not afford dignity. More specifically, Reporting party (RP) states that R1 has a wound on the right knee for months that reopens because R1 crawls on the floor and R1 complained of pain in her hip.  RP further stated they did not observe any injuries.  Physician’s Report dated January 20, 2025, states Resident #1 (R1) is non-ambulatory and diagnosed with Parkinson's disease and dementia, and with a history of ataxic gait, dysphonia, cerebrovascular accident. R1 struggles with speech and movement. Interviews were conducted with facility staff, the administrator as well as responsible party.  Staff interviews and R1's responsible party confirmed that R1 had a skin condition which was monitored and that appropriate wound care was provided.   R1 was observed during the visit and appeared clean alert and responsive.  R1 responsible party confirmed R1 occasionally crawled on the floor, and both the  staff and the responsible party encourage the use of a  wheelchair.  They also state that  R1 was new to the facility, and the staff were working as a team to address R1's needs, including care related to an undiagnosed brain condition.   There is not a preponderance of evidence the facility failed to provide adequate care and uphold our one's personal dignity Regarding the allegation, facility did not meet resident's incontinence needs and Inappropriate space used for resident's sleep. More specially, R1 incontinence brief was removed and wet and that R1 may have been not been sleeping on their bed..  Interview with administrator reveal  staff regularly attempt toileting routines with R1, though these are often unsuccessful.  Responsibly party as well as staff interviews reveal R1 often removes incontinence brief due to behavior tendencies.  Interviews further reveal R1 has a pattern of  crawling off the bed and around their room.  LPA observed R1's bed to be positioned as low to the ground as possible, with and additional mat placed on the floor to protect R1 should they leave the bed.  Staff explained the mat is to support R1's safety and preference for tight spaces due to behavior factors.  A review of records as well as LPA observations reveal that's sufficient staffing is in place to meet residents needs including incontinence care. (Continued on LIC999C) (Continued from LIC9099C) ( page 3 of 3) Regarding the allegation, Inappropriate use of video surveillance. More specifically, there was a surveillance camera in R1's bedroom. According to an interview with R1's responsible party, they confirmed they provided a camera in R1's room.  LPA observations of R1's room revealed no camera in the room during a tour.  The administrator confirmed there was a camera temporarily placed in R1's room with R1's responsible person's knowledge and consent.   The administrator further reported that they took the camera out of R1's room after discussing it with R1's responsible party. Interviews and documentation indicated the camera did not record audio. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED. A copy of this report along with licensee rights was given to Co-Administrator Jenny Sequeira whose signature below confirms receipt of these rights.