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32 | Regarding the allegation: Staff are not following physician’s order for resident’s medical needs. It was alleged staff did not follow R1’s physician’s orders pertaining to their walker. To investigate the allegation, LPA attempted to interview one (1) resident and two (2) staff members. LPA attempted to interview R1, but they no longer reside at the facility. LPA’s interview with S1 revealed R1 moved out of the facility into a smaller facility due to them needing a higher level of care. S1 stated, R1’s representative did not choose to pay for optional services such as one (1) to one (1) Supervision Program. Per S1, R1’s cognitive impairments had resulted in an increase in falls and although they had a walker they would forget to use it. LPA’s interview with S2 correlated with S1’s interview. S2 stated they self-reported R1’s falls on an Unusual Incident/Injury Reports (SIRs).
LPA conducted a record review of R1’s file. LPA’s record review of R1’s Physicians Visit dated 3/24/2026 confirmed R1 to need their walker. R1’s initial Needs and Services Plan dated 8/29/2022 documented R1 as ambulatory without needing assistance. However, R1’s Needs and Services Plan dated 4/12/2026, documented their change of condition to reflect their need of a walker and in need of supervision due to their inability to follow instructions. R1’s Physician’s Report dated 2/18/2026 confirmed R1 could not follow directions/instructions due to their diagnosis. LPA’s record review confirmed the facility did report R1’s falls to the appropriate reporting parties including Community Care Licensing Division (CCLD). Additionally, LPA’s review of R1’s Admission Agreement confirmed they did not have Optional Items and Services to be notated. Further record review of R1’s Notice of Resident Moving Out dated 4/15/2026 documented their reason of moving as, “Higher level of care”.
During LPA’s physical plant tour, LPA observed a variety of residents to be using assistances devices to ambulate such as walkers. Additionally, LPA observed a variety of staff members assisting residents to the common areas, food preparation and medication.
Based on interviews, record review and observations there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.
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