complaint·May 2, 2022

Facility is retaining a resident with prohibited health condition - UNSUBSTANTIATED Review of a Resident Appraisal form dated 4/20/2020 the resident has a history of sores (pressure) on their bottom as well as a history of pneumonia, dehydration, UTI hospitalizations prior to placement in facility. It was noted under “Special medical attention” that the resident has ongoing home health due to sore on bottom. In the “Physical Health portion of the resident’s “Appraisal/Needs and Services Plan” dated 06/01/2021, NEEDS column states the resident has a need to prevent skin breakdown/heal, with an objective/plan to reposition frequently. The time frame is “ongoing.” The person(s) responsible for implementation are staff, and the method of evaluating progress is visual. According to a Physician Care Record dated 4/03/2021 R1’s physician examined the wound on their bottom and ordered home health, no staging of the pressure injury was noted. 9/03/2021 states R1 went in for a checkup and physician prescribed antibiotics for a wound on R1’s right toe. Doctor ordered home health for R1’s toe and bottom. A fax cover sheet from home health dated 12/23/2021 notes that R1 was discharged from home health with a well healing stage 2. 12/30/21 Reason for visit was for the doctor to look at R1’s bottom, the doctor noted that R1’s wound is not bad and healing, no need for home health. On 2/20/22 it was noted that the doctor prescribed a cream to put on R1’s sore bottom. 2/17/2022 notes R1’s doctor prescribed antibiotic cream for the sore on R1’s bottom. On 2/24/2022 doctor prescribed Augmentin twice daily. No staging of the pressure injury was included in these notes. On 3/03/2022 R1 returned to their doctor for a wound check and the physician stated the wound had progressed from a stage 2 to a stage 3. Doctor ordered a new cream for the wound and a referral to home health and wound care. A Physician Visit Communication form dated 03/03/2022 notes that R1 went to the doctor for a wound check and was referred to the local hospital for wound care. Continued on LIC9099-C During interview with administrator it was learned that R1 moved into the facility from a skilled nursing facility in 2020. When R1 moved into the facility they already had a sore on their bottom and the facility has been managing the sore since R1 moved in. Since R1 moved into the facility R1 has been taken to their doctor multiple times for the wound to be examined and treated. R1 has been prescribed different topical and oral antibiotics to treat the wound. Home health has been coming in 2-4 times per month to treat the wound. R1’s physician has not staged the pressure injury past a stage 2. Although it is a restricted health condition, the licensee may provide care for residents who have Stage 1 and 2 pressure injuries. Staff interviews confirmed that R1 has been receiving treatment for a pressure ulcer. 4 of 5 staff confirmed they have been trained on how to care for a resident with pressure injuries. Facility is not seeking medical attention – UNSUBSTANTIATED Review of documents revealed that R1 has been attending regular check-ups with their physician. R1 has also been taken to their physician for a series of wound checks and other health related appointments. In addition, R1 has had the services of home health at the facility on multiple occasions. During staff interviews 5 of 5 staff stated that R1 was taken to their doctor to be treated. 5 of 5 staff stated that home health comes in to treat R1 for pressure ulcers twice per week. Administrator confirmed that R1 has been taken to see their doctor regularly. Continued on LIC9099-C Facility failed to address change in condition - UNSUBSTANTIATED Review of documents revealed that R1 has been attending regular check-ups with their physician. R1 has also been taken to their physician for a series of wound checks and other health related appointments. In addition, R1 has had the services of home health at the facility on multiple occasions. During staff interviews 5 of 5 staff stated that R1 was taken to their doctor to be treated for a pressure ulcer. 5 of 5 staff stated that home health comes in to treat R1 for pressure ulcers twice per week. Facility retaliates against staff who file complaints – UNSUBSTANTIATED During staff interviews it was learned that 4 of 5 staff know how to report incidents to Community Care Licensing. 4 of 5 staff stated the facility does not discourage staff from reporting incidents. 4 of 5 staff stated that the facility does not retaliate against staff who report incidents. At the time of interview 1 staff had not yet been trained on reporting requirements because they are a new employee. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was emailed to facility administrator Audra Audino. No deficiencies were cited on today’s date.