Complaint Investigation Report

On 04/17/2024, another Physician communication sent by the facility indicated that R1 had aggressive behaviors toward staff including trying to hit Staff with their cane and attempted to slam doors into staff members. There are frequent communications between the primary physician of R1 and facility staff during March 2024 and April 2024. The primary basis for these communications is the fact that R1 is extremely physically combative and aggressive with staff as well as refusing antibiotic medications for the lower left leg injury/wound. The facility has documentation asking the primary physician of R1 for home health agency orders regarding these issues and requesting guidance. The Skilled Nursing Facility (SNF) transfer orders for R1 into the facility above on 01/12/2024 indicated that R1 has a primary diagnosis of dementia with agitation and psychosis. R1 needed supervision and assistance with Showering/Bathing Activities of Daily Living (ADL) including staff providing physical steadying assistance, lifting, holding, supporting, and providing partial/moderate assistance. Narrative charting from the facility indicated that on 03/29/2024, R1 had a staff assisted shower and stated that staff members “dunked them in chemicals.” Staff members documented that R1 had the wounds on their lower left leg cleaned and had antibiotic cream applied by staff as well as bandages. On 03/23/2024, narrative charting by the facility stated that R1 was aided in the shower and R1 stated staff “intentionally put soap in their eyes and only used cold water.” Facility narrative charting from January 2024 through March/April 2024 indicates that R1 is very disruptive and combative to both staff and other residents while eating in the dining room and in the bathroom during grooming/bathing. All staff interviewed by LPA indicated that they provided antibiotic cream to the affected wounds on R1’s lower leg and cleaned/bandaged the area but did not scrub or touch the area in a rough manner. All residents interviewed by LPA stated that they have not had any issues with staff supervision and/or assistance during ADLs including bathing and/or grooming.

Based on the information obtained, there was insufficient evidence that staff do not maintain a comfortable room temperature for resident(s). Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff are not providing resident with adequate drinking water. It is alleged that staff do not give R1 any water so R1 drinks water out of the faucet and if the faucet water were to get turned off, R1 would have to drink the toilet water.

On 05/01/2024, LPA conducted an initial 10-day complaint investigation visit to the facility above. During this visit, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA visually observed the dining/food service area as well as the kitchen area of the facility. Continued on 809-C