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32 | Regarding the allegation that facility staff prevent resident from accessing their own rooms: it was alleged that R1’s room in memory care was locked to keep them out of their room, staff would not open the door for R1 despite R1’s request, and multiple resident rooms in the memory care unit are locked during the day to keep residents out of their rooms and in the common area where they can be more easily observed by staff. On November 5, 2024, LPA Haddad inspected the memory care unit and observed there were approximately 29 residents present, most of whom were in the common area. LPA conducted health and safety checks on the 29 residents present and did not observe any health and safety issues. LPA inspected 23 resident rooms in the memory care unit and observed six of the resident rooms were locked. Two of these locked rooms were occupied, but four of the locked rooms were unoccupied and the residents who lived in these rooms were in the common area. LPA noted that the doorknobs can be locked and unlocked from the inside, but need a key to be opened from the outside, so it is possible for a resident to enter their room and lock it from the inside and it is also possible for a resident to lock the door as they leave the room, close the door behind them, and lock themselves out. LPA also observed multiple residents moving freely between the common area and their rooms, with some residents locking their doors after they entered their rooms. LPA interviewed four staff who denied the allegation, stating that staff do not lock resident doors, sometimes residents accidentally lock themselves out of their rooms, and staff will unlock their doors for them to let them back in. LPA interviewed AD who denied the allegation. LPA interviewed five residents in the memory care unit, including R1, and was unable to obtain reliable information regarding the allegation. The information obtained is conflicting.
Regarding the allegation that facility staff are not seeking timely medical attention for resident: it was alleged that on October 29, 2024, R1 was in pain, the facility did not obtain proper medical attention for R1, and by October 30, 2024, R1 was still in pain and had clearly visible swelling on their right leg. LPA Haddad interviewed AD who stated that on October 29, 2024, they were advised that R1 was complaining about pain, they went to see R1 with R1’s home health nurse who assessed R1 and applied a lidocaine patch to R1’s right leg, AD notified R1’s hospice on October 29 or 30, 2024, and facility staff do not know how or when R1 sustained this injury. One staff interviewed stated that when R1 initially complained about pain, there was no evidence of injury. LPA interviewed R1’s home health nurse who stated that when they assessed R1, R1 had leg pain but no swelling, it was unknown what caused the pain, and they applied a lidocaine patch to R1’s leg. |