Complaint·January 9, 2025

During the visit, LPA observed residents, attempted to interview residents and interviewed staff. LPA attempted to interview five residents, however due to their dementia, they were unable to answer questions or provide any information regarding the allegation. Residents observed were in clean clothes, and did not have a urine odor. Based on staff interviewed, staff changes residents 2-3x a day; before breakfast, after lunch and before bed. Staff indicated that they may change residents less or more often depending on the resident's service plan. According to staff, if residents soiled their diapers/clothes, staff would immediately check on the resident and change them if required. Regarding the allegation, staff did not adequately address a change in resident’s condition, according to the reporting party, R1 was admitted to the facility in May 2024 and was assessed as needing Level 2 care, however in June 2024, the facility reassessed R1 and indicated R1 is now Level 4 care. During the investigation, LPA requested to review R1's file, however LPA did not observe any completed reappraisals, service plans, or pre-appraisal appraisal. According to the Administrator, he was not the administrator at the time of the incident. In addition, according to the Resident Services Director, she is unsure why the file is incomplete as she was not employed at the facility when R1 was admitted. Regarding the allegation staff did not seek timely medical attention for a resident, according to the reporting party, R1 was found not responding to stimulus and was transported to the hospital. During the investigation, LPA reviewed documents and interviewed staff. According to the Resident Services Director, on July 4, 2024 at around 12pm, R1 was walking towards his/her room with R1’s responsible party when R1 suddenly became unresponsive. Med-tech and Resident Services Director immediately came to assist R1 and check his/her vitals. 911 was called and paramedics came to the facility at 12:05pm and transported R1 to the hospital. Regarding the allegation staff did not assist resident with repositioning, according to the reporting party, during multiple visits conducted, it was found that R1 was left unattended on a wheel chair and was not being repositioned by staff. Continue to 9099C During the investigation, LPA reviewed R1's file and interviewed Resident Services Director. LPA was unable to find any completed reassessments and/ or service plans to indicate that R1 required repositioning. According to the Resident Services Director, R1 was able to walk with a walker but at times needed a wheelchair. Based on the physician's report dated 12/28/2023, R1 was listed as ambulatory. According to a staff member interviewed who was employed during the time R1 was at the facility, R1 did not need repositioning as he/she was able to walk with a walker. In addition, it was stated R1 required assistance getting up from bed and getting back down in bed. Based on the interviews conducted and information collected, the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation is unsubstantiated at this time. Report is reviewed with Resident Services Director, Maryanne Rodriguez and a copy is provided