complaint·November 21, 2022

Page 2 Facility staff did not properly care for resident's pressure sore - UNSUBSTANTIATED LPA requested and received medical records from the local hospital that provides care for R1. There was no mention of R1 having pressure injuries in the responsive records. LPA did receive a “Quick Notes” document that was written by R1’s physician dated 6/29/2022 which states that R1 no longer had a wound on the end of the left great toe, the skin is Intact, no new wounds were seen, wound healed. 5 of 5 staff stated they had been trained on how to care for pressure injuries. Administrator stated in regard to the spot on R1's toe the home health nurse said there was nothing she needed to do with it. The facility coordinated with the home health nurse who suggested that it should be monitored, the family was OK with this decision. It was determined that R1 did have a abcess on their toe and per R1’s physician the wound had healed. Staff have been trained on how to properly care for pressure injuries should a resident have a pressure injury. This allegation is unsubstantiated. Facility staff do not properly assist residents with oxygen - UNSUBSTANTIATED It was alleged that facility staff do not properly assist residents with oxygen. R1’s Care Plan notes that R1 needs assistance overseeing R1’s care with oxygen. Resident is on oxygen at 2 liters continuously. Resident is independent in changing from their room concentrator to O2 tanks as needed. Staff will assist with filling humidifier bottle and change of tubing monthly. Ensure resident is using their portable oxygen tank for all meals. Resident is to dial the valve to CF2 and 0 when they are hooked up to their portable tank. Resident is now on continuous oxygen at 2L min via nasal cannula. Resident is to utilize the portable oxygen tank anytime they are outside of their room. Continued on LIC9099-C Page 3 Staff interviews revealed that staff have been trained to ensure the resident is wearing the nasal cannula correctly, check the output and make sure the oxygen tank is not running out. Administrator stated R1's portable oxygen tanks were running out quickly. R1 takes a long time to eat their meals and one oxygen tank would not last through an entire mealtime. R1 started to eat in their room. R1 takes their oxygen off frequently. R1 should not go out for meals anymore, but the family made a decision that they were OK to go out and eat and to doctors’ appointments without R1's oxygen. It was determined that even though R1’s Care Plan directs that R1 should utilize their portable oxygen tank anytime they are outside of their room R1 chooses to take their oxygen off frequently, staff cannot make R1 wear their oxygen. Facility also cannot force R1’s family to ensure that R1 uses their oxygen when they take R1 out of the facility. This allegation is unsubstantiated. Facility staff do not properly conduct transfer assistance for residents - UNSUBSTANTIATED It was alleged that facility staff do not properly conduct transfer assistance for residents. 5 of 5 staff stated they had been trained on how to properly assist in transferring residents. The training was conducted by the Director of Health & Wellness, visiting physical therapists and facility Med Techs. This allegation is unsubstantiated. Facility staff do not meet the care needs of the residents - UNSUBSTANTIATED It was alleged that facility staff do not meet the care needs of the residents. There was not enough information provided by the complainant. LPA was unable to make further contact with the complainant due to unreliable contact information provided in the complaint, and the allegation is too vague. This allegation is unsubstantiated. 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 provided to facility administrator Sue Todd.