Complaint·July 22, 2021

According to R1’s physician’s report, R1 is ambulatory and has no motor impairment. There was no special instruction in R1’s physician’s report for the facility to follow to prevent falls prior to incident. -- Staff leaving residents in soiled diapers for extended periods of time: According to administrator, continence care is provided to residents every 2 hours; hourly if a resident has a condition. Facility staff logs continence care provided in a chart inside the resident's apartment per administrator. According to facility records, continence care was provided to Resident 5 (R5) regularly for June 2019, as documented by facility staff. -- Staff was unable to locate a resident while in care: According to records review conducted, on August 23, 2019, CCL unsubstantiated a complaint allegation that Resident 4 (R4) left the facility unauthorized. According to R4’s physician’s report, R4 was able to leave the facility unattended, can communicate needs and follow instructions. According to facility records, R4 signed out prior to leaving the facility and signed in upon return. -- Staff failed to notify authorized representative of residents incidents: According to staff interviews, S1 stated that the person responsible for the resident is notified of incidents verbally. According to facility records, the May 31, 2018 fall incident was reported to the person responsible for the resident as documented by facility staff. -- Staff administered discontinued medication to a resident: According to Physicians Orders dated March 13, 2019, the medication FUROSEMIDE (aka LASIX) 40 mg is to be discontinued for R2. According to facility records, this medication was last administered to R2 around noon of March 2, 2019, as documented by facility staff. The allegations were deemed UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.