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32 | (Continued from LIC 9099)
In December 2025, prior to being admitted to the facility, Resident #1 (R1) had a fall in the home and was diagnosed with a right intertrochanteric femur fracture that required surgery which was completed on December 9, 2025. R1 was then admitted to a Skilled Nursing Facility (SNF) on December 12, 2025, and was released to the this facility on January 23, 2026. Per Medical Assessment dated 1/23/2026 R1’s requires orthopedic aftercare and is non-ambulatory. Appraisal Needs and Services Plan and Pre-Appraisal dated 1/23/2026 state R1 has major neurocognitive disorder. On January 9, 2026, a Capacity Assessment was signed by the physician that R1 has major neurocognitive disorder and agitation.
It was alleged that Resident sustained multiple bruises while in care. LPA reviewed Medical Assessment dated 1/23/2026, Appraisal Needs and Services Plan dated 1/23/2026 Preplacement Appraisal dated 1/23/2026 and the Skilled Nursing Facility Discharge Summary dated 1/23/2026. Documents reviewed revealed no documentation of bruises on Resident #1 (R1). LPA interviewed three of three staff members who all stated R1 came to the facility with various stages of bruising due to the orthopedic surgery. Three of three staff denied the allegation that bruises occurred while in facility care. Two of three witnesses interviewed also stated R1 had bruises prior to coming to the facility and was prone to bruising and denied that the facility caused the bruises. One of three witnesses could not confirm, nor deny the allegation. Resident #1 was interviewed and was asked if bruises occurred while in care. R1 answered No. Two other residents were asked about care provided at the facility and two of two residents stated they receive good care from the staff.
LPA also investigated the allegation that Staff do not ensure resident receives adequate care with personal grooming assistance. R1 has a history of psychosis and refusing medications or personal assistance. Two of three witnesses stated that while R1 had a history of not changing, or showering prior to moving into the facility. Two of three witnesses stated that they do not believe the facility is not offering these services but feel that R1 refuses these services. One of three witnesses could not confirm nor deny the allegation but did state R1 would be a challenging patient but hoped with time that this may change. LPA interviewed three of three staff who all denied the allegation. Staff reported they sponge bathe R1 daily and clean fingernails with wipes daily. LPA interviewed R1 to ask if they were happy with services being provided, which included personal care and R1 answered Yes.
(Continued on LIC 9099-C1)
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