complaint·October 21, 2022

Complaint alleges that staff do not prevent resident from falling out of bed. Based on interviews that were conducted, LPA could not prove or disprove that the staff do not prevent the resident from falling out of bed. Furthermore, inconsistent statements were made during the course of the investigation. In addition, LPA reviewed facility documents that could not corroborate the allegation. However, during the course of the investigation and facility records review, LPA learned that there was only one LIC 602/Physician’s assessment that was made during R1’s residency at the facility from March 2022 through August 2022. (See LIC 809- Case Management-Deficiencies dated for October 21, 2022) Complaint alleges Staff do not provide a safe and healthful environment by over medicating resident. During the course of the investigation, LPA reviewed the Medication Assessment Record dated for June 2022. LPA learned that there was a medication change on June 15, 2022 by the Nurse Practitioner that changed the medication dosage for R1. However, during this medication change, the pharmacy did not get the order in time and thus a missed medication was documented on the Medication Assessment Record for June 15, 2022. Based on interviews that were conducted, LPA could not prove or disprove the allegation. Complaint alleges that Staff do not provide a safe and healthful environment by yelling at resident and visitor. During the course of the investigation, LPA reviewed facility documents including facility notes and facility sign-in sheets. Furthermore, LPA could not corroborate the allegation. In addition, based on interviews that were conducted, LPA could not prove or disprove that the staff do not provide a safe and healthful environment by yelling at resident and visitor. Complaint alleges that Staff do not assist resident with meal needs. LPA reviewed facility documents and conducted interviews. LPA could not prove or disprove that the staff do not assist resident with meal needs. Based on interviews that were conducted, meals and food service were not a concern during R1’s residency at the facility. Complaint alleges that Staff do not safeguard resident's property. LPA reviewed facility documents and facility notes and could not corroborate the allegation. Based on interviews that were conducted, LPA could not prove or disprove the allegation. Furthermore, during these interviews, dates and times of the property that was allegedly not safeguarded was unknown. (Report continued on LIC 809C) Complaint alleges Staff do not assist resident with wheelchair transfer and Staff in violation of admission agreement for resident activities. During the course of the investigation, LPA reviewed facility documents and conducted interviews and could not corroborate the allegation. Based on interviews that were conducted, LPA could not prove or disprove the allegation. A finding that the complaint allegations of Staff do not assist resident with incontinence needs, Staff do not prevent resident from falling out of bed, Staff do not provide a safe and healthful environment by over medicating resident, Staff do not provide a safe and healthful environment by yelling at resident and visitor, Staff do not assist resident with hygiene needs, Staff do not assist resident with meal needs, Staff do not assist resident with wheelchair transfer, Staff do not safeguard resident's property, Staff in violation of admission agreement for resident activities are unsubstantiated meaning that although the allegations 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 allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.