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32 | investigation, including, but not limited to staff and resident roster, residents’ physician’s report, admissions agreement, appraisals, need and service plan and other documents. After the initial visit, LPA requested and received R1’s medical records from the hospital, and they were reviewed on February 3, 2026.
Allegation #1: Staff did not seek timely medical attention for resident.
It was alleged that facility staff did not seek medical attention in a timely manner for resident #1 (R1’s) altered mental status. LPA review of R1's file revealed the following: R1 was assessed and admitted to the facility on October 15, 2025; LPA interview with executive director (ED) and other staff revealed that R1 and all the residents are receiving adequate care and supervision by facility staff, and that 911 emergency service calls are made by staff if necessary.
LPA interviews with thirteen (13) out of eighty-one (81) residents state that staff provide satisfactory care and supervision. R1’s physician's report does not identify that R1 had altered mental condition. A review of hospital medical records also did not provide any information to support the allegation.
Therefore, based on LPA interviews and record review, the allegation is Unsubstantiated at this time.
Allegation #2: Staff neglect resulted in resident developing a pressure injury.
It was alleged that R1 developed a pressure injury while in care at the facility. ED and other staff indicated that R1 had no pressure injuries. A review of R1’s facility file and hospital records did not provide any information to verify that R1 developed pressure injuries. There was no indication that R1 developed any pressure injury. The information available during this investigation does not verify the allegation. Therefore, based on interviews and record review and due to lack of supporting evidence, the allegation is unsubstantiated at this time.
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