During today's visit starting at 10:10 a.m. LPA and staff briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations.

On the allegation, Resident sustained multiple injuries due to staff neglect or physical abuse, it is the concern of the Reporting Party (RP) that R1 had unexplained bruises and scratches on their back and buttocks area. To investigate this complaint, LPA conducted in person interviews, file and record review, and obtained copies of pertinent documentation relevant to the investigation.

Interview with R1 revealed that they are alert, oriented, and demonstrate appropriate decision-making capacity. R1 has lived in the home for approximately one (1) year and reported having no concerns regarding the quality of care provided by staff. R1 stated they are not abused or neglected by staff. When asked about the bruises and scratches, R1 explained that they frequently scratch themselves due to ongoing issues with itchy skin. Regarding the bruises on their back, R1 stated that their insurance delivered the incorrect bed gel; they were supposed to receive an air loss mattress but were sent a different product. R1’s authorized representative has already contacted the insurance provider to request a replacement. In the meantime, staff assist R1 by placing a wedge and repositioning them regularly.

Interview with the AR revealed that R1 is alert, oriented, and able to communicate their needs. The AR stated that if any issues were occurring, R1 is capable of expressing their concerns, including concerns related to neglect or physical abuse. The AR reported having no concerns regarding the care being provided to R1.

Staff interviews revealed that R1 is alert and able to communicate their needs. Staff deny neglecting R1 and deny witnessing any other staff neglect R1. Staff also deny physically abusing R1 and deny witnessing any staff engage in physical abuse. Staff reported that R1 had recently been discharged from hospice and was previously using an air loss mattress. When R1 transitioned to home health services, the mattress was changed, which has caused some discomfort. The AR was informed and contacted R1’s insurance, though the replacement process has taken some time, which may explain the bruising. Staff report that they regularly reposition R1 and utilize a wedge for comfort.

Report continued on LIC 9099-C PAGE 3...

Records review, including but not limited to the medical assessment, body assessments, resident appraisal, needs and services plan, physician visit forms, outside agency documentation (including wound care), and home health records, revealed that R1 does not have a Major Neurocognitive Disorder (NCD) diagnosis. Documentation shows that R1 has multiple wounds on their legs, is able to communicate, follow directions and instructions, express frustration, and is bedridden due to advanced age and disease progression. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Resident sustained multiple injuries due to staff neglect or physical abuse is deemed unsubstantiated at this time.

On the allegation, Staff are not meeting the care needs of resident in care, it is the concern of the Reporting Party (RP) that it appeared R1 had months of dead skin on their legs and feet. To investigate this complaint, LPA conducted in person interviews, file and record review, and obtained copies of pertinent documentation relevant to the investigation.

Interview with R1 revealed that they have a wound on their left leg that was previously treated by hospice and is now being treated by home health. R1 stated the facility provides minimal assistance with the wound, as treatment is primarily the responsibility of the wound care specialist. R1 reported that aside from the wound on their left leg, facility staff meet their care needs, respond promptly to their requests, and R1 has no concerns regarding the quality of care they receive.

Interview with the AR revealed that R1 is alert, oriented, and able to communicate their needs. The AR stated that R1 is capable of expressing any concerns related to their care. The AR reported having no concerns regarding the care being provided to R1. The AR also noted that R1 is in the process of obtaining an appointment with a podiatrist; however, insurance approval has been delayed, and the AR clarified that this issue is unrelated to facility staff.

Interviews with staff revealed that R1 is currently receiving services from a wound care specialist for a wound on their leg, with a nurse addressing the wound once a week. Staff stated that R1 was previously on hospice and later transitioned to home health services. Staff described R1 as alert, oriented, and able to communicate their needs. Staff believe R1’s care needs are being met and reported that R1 would vocalize concerns directly to staff if needs were not being met. Report continued on LIC 9099-C PAGE 4...

Records review, including but not limited to the medical assessment, body assessments, resident appraisal, needs and services plan, physician visit forms, outside agency documentation (including wound care), and home health records, revealed that R1 does not have a Major Neurocognitive Disorder (NCD) diagnosis. Documentation indicates that R1 has multiple wounds on their legs, is able to communicate, follow directions and instructions, express frustration, and is bedridden due to advanced age and disease progression. Wound care documentation notes wounds on the left leg and buttock area. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff are not meeting the care needs of resident in care is deemed unsubstantiated at this time.

Exit interview conducted. Report was reviewed and a copy was provided.