complaint·May 4, 2021

LPA reviewed R4’s and R5’s LIC 602A’s and LIC 625’s, and it was noted R4 and R5 could not bathe self, could not dress/groom self, could not care own toileting needs. Both R4 and R5 did not have dementia but had mild cognitive impairment. There was no skin breakdown noted. Between 5/11/2020 and 9/23/2020, 6 residents were interviewed with 5 being successfully interviewed as 1 was not able to communicate. 5 out of 5 residents (including R1, R4, and R5) stated their needs were being met in the facility. LPA observed all 6 residents were clean and well kempt. Between 5/11/2020 and 4/7/2021, 2 staff were interviewed. 2 out of 2 staff stated R1’s condition changed. Although there was no documentation, 2 out of 2 staff stated they made sure they turned R1 at least every 2 hours. Also, 2 out of 2 staff observed other caregivers turned R1 at least every 2 hours. No resident has wound or pressure injuries per staff. Based on record review, the facility did not have fire clearance to retain a bedridden resident. An LIC 625 dated 5/5/2020 indicated the administrator observed R1 who could not hold any utensil or food anymore; R1 could not reposition self and staff had to reposition R1. There was no indication of skin breakdown. A medical note dated 6/19/2020 was noted to indicate that R1 needed higher level of care and be moved to a complete care facility. Based on interviews, and records review, the department has determined that the allegation was UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. This report was emailed to Licensee for review and signature. Based on staff interview, R1 could not turn and reposition or feed self. R1 was interviewed but could not provide any information. R1 was observed not able to reposition oneself. An LIC 625 of R1 dated 5/5/2020 revealed that R1 could not feed oneself. Staff had to feed R1. Also, R1 became bedbound and could not reposition without staff’s help. The Review of the facility’s fire clearance revealed that the facility did not have bedridden fire clearance. Thus, the facility was not a suitable placement for R1 to stay and cannot retain R1. Based on records review, on 5/5/2020, the facility initially issued a 60-day courtesy notice to R1 and responsible party advising that the facility could not retain R1 who is bedridden so R1’s responsible party had more time to look for another placement. On 6/10/2020, an official 30-day eviction notice was issued to R1, responsible party, and the Department. On 6/19/2020, a medical note was issued to R1 indicated that R1 needed higher level of care and be moved to a complete care facility. Based on the Department's interviews, observation, and records review, the allegation is UNFOUNDED, meaning it was false, could not have happened and/or is without a reasonable basis. This report was emailed to Licensee for review and signature.