complaint·September 1, 2022

As to the allegation of, “Staff are not meeting the needs of resident who uses a catheter,” It was discovered through interviews and documentation that Resident 2 (R2) requires a condom catheter. R2 has home health and hospice services that come to the facility and control the supply of condom catheters. On 08/16/2022, LPA Jeffries observed and photographed a box of condom catheters (approximately 1-15 catheters) for R2. Interview with licensee on 08/16/2022 revealed that the care instructions for R2’s catheter changes is to replace catheter with a new condom catheter at each change. Interviews of Staff 1 – 6 confirm that the new catheter is used on each change of R2. On 08/26/2022, LPA interviewed R2 who stated that all their needs are being met by the facility and have had no complaints about the facility. Based on interviews, observations, and photographic evidence there is not enough evidence at this time to support the allegation of, “Staff are not meeting the needs of resident who uses a catheter.” and is unsubstantiated at this time. As to the allegation of, “Staff did not prevent a resident from choking while in care.” It was discovered through interviews and documentation that there was no witness to come forward or no resident to be identified related to a choking incident. All residents R 1-6 who were able to be interviewed had never had a choking incident while in care. There were no documented incident reports of a resident choking while in care. Interviews of Staff 1-6 do not recall a resident choking while in care as described in this allegation. LPA reviewed staff written account of resident progress notes dated April 1, 2021 through June 30, 2021 and did not see an instance of resident choking nor any days of progress notes during that time missing. Due to documentation and interviews, there is not enough evidence at this time to support the allegation of, “Staff did not prevent a resident from choking while in care.” and is unsubstantiated at this time. As to the allegation of, “Staff are not providing appropriate care and supervision to the resident while in care.” It was discovered through interviews and documentation that staff document daily progress of residents. Progress reports of residents during the time of April 1, 2021 through June 1st of 2021 do not indicate any instance of residents needs not being met in a timely manner. Interviews of Residents 1 – 6 did not reveal that any of the residents do not have an issue with being assisted in a timely manner. Interviews of Staff 1 thorough 6 staff did not indicate that residents had to wait to be assisted. During the time of the complaint the staff schedule indicated adequate staff numbers present during the day, minimum average of 1:3 ratio on day shifts and minimum of 1:5 ratio doing the overnight hours shifts. At this time, there is not enough evidence to support the allegation of, “Staff do no assist resident in timely manner.” and is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegations of, “Facility has inadequate record keeping.” It was discovered through interviews and documentation that, as it pertains this allegation of this complaint, there were corresponding documentation during the time of April 2021 through July of 2021 to indicate adequate record keeping was being implemented. Facility handwritten resident progress notes during that time noted two incident reports of resident, the first occurring on 06/09/2021 and the second occurring on 06/16/2021, both incidents reported and both incidents were recorded in the resident progress notes. LPA reviewed all written resident progress notes during April 2021 and June 2021 and no other reportable incidents were logged. Interviews of Staff 1 -6 indicated that they are instructed to write down progress notes near the end of their shifts and any incidents are reported to Administrator/Licensee. Residents who were identified in this allegation were not available for interviews. Due to documentation, record reviews and interviews, there is not enough evidence to support the allegation of, “Facility has inadequate record keeping.” and is unsubstantiated at this time. Exit interview, report singed, and report emailed.