Complaint Investigation Report

Previous staff interviews acknowledge witnessing S1 provide insulin injections prior to obtaining their license.

Interviews from previous and current staff acknowledged that R1 needed assistance with bathing, dressing, grooming, and incontinence care. Interviews stated that R1’s was incontinent of bladder and bowel. Staff stated that, for most of R1’s stay at the facility, R1’s POA refused to provide proper incontinence products for R1. Therefore, when R1 would become incontinent, this required a change of clothing. Additionally, staff stated that it was difficult for R1 to comply with incontinence care. Nursing notes also detail R1’s refusal for showers.

Interviews and nursing notes detail repeated times where R1 was observed walking without their walker. Nursing notes also detail staff attempts to have R1 use their walker. Nursing notes also detailed R1 would refuse to use their glasses or leave them in other resident apartments. R1’s physicians report indicated that they had motor impairment/paralysis and needed to use a walker to prevent falls. Additionally, R1 had a history of seizures which led to additional falls. Therefore, due to R1’s history of seizures and falls, along with wandering behavior, the facility failed to provide proper supervision. Additionally, R1’s care plan was not updated as required based on level of care.

Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.