complaint·June 27, 2025

LPA upon receipt from the hospice company. LPA also obtained hospital records for R1. Throughout the course of the investigation, LPA Dulek reviewed all documents received. The following was then determined: Allegation “Staff did not ensure resident received proper wound care while in care:” It was alleged that R1 had multiple wounds on their face and head and was not receiving proper treatment for these wounds. Record review revealed that prior to moving into the facility, R1 had lived alone and was independent. On 04/16/2024, R1 was found in their private home on the floor and was taken to the hospital. Upon admit to the hospital, R1 was “critically ill” and suffering from multiple health conditions, both acute and ongoing. Records indicate that upon admit, R1 had an ulcerated dermal mass at the right preauricular region (in front of R1’s right ear,) which appeared to be squamous cell carcinoma or basal cell carcinoma. R1 also had a right parotic exophytic mass (a mass on R1’s neck near their ear, growing outward,) which also appeared to be cancerous. Due to R1’s age and prognosis, no surgical interventions or treatments for these masses were indicated and instead, medical professionals discussed both palliative care and hospice care options with R1. While in the hospital, R1 was diagnosed with metastatic melanoma, which remained untreated while in the hospital. R1 was discharged from the hospital on 05/03/2024, with no ongoing treatment plans indicated for these identified masses. R1 was admitted to hospice care on 05/05/2024 with a diagnosis of melanoma. According to staff interviewed, the hospice nurse provided medical treatment to R1 as needed and documented treatment in R1’s hospice care plan. Record review revealed that R1’s alleged “wounds” were not pressure injuries or surgical wounds at all but were carcinoma masses instead. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Allegation: “Facility retained a resident with a higher level of care need:” The complaint alleges that the facility retained R1 even though R1’s needs exceed assistance available under Title 22 regulations. Initially hospital records indicated “will need eventual hospice SNF (Skilled Nursing Facility) placement." However, on 04/25/2024, hospital doctors ordered R1 to be discharged to board and care and hospice. It was confirmed on R1’s medical records that R1 was discharged to the facility on 05/03/2024 at 04:20PM and had an order for hospice care. However, R1 refused to sign papers admitting them to hospice care prior to discharge from the hospital and stated, “not today.” R1’s hospital discharge Report Continued on LIC 9099-C (p.3) summary dated 05/03/2024 indicates R1 was “determined to be medically stable for discharge to board and care with tentative plan to initiate hospice.” R1’s physician’s report dated 05/03/2024 indicates that R1 did not require assistance with all activities of daily living, nor did it indicate diagnoses of any other restricted or prohibited health conditions. R1’s physician indicated that R1 was non-ambulatory at that time. Interview with Administrator and record review revealed that R1 was admitted to hospice care on 05/05/2024 with a diagnosis of melanoma. LPA was unable to interview R1 related to the allegation as R1 was hospitalized on 05/12/2024 and passed away while in the hospital. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Allegation “Staff did not ensure resident’s hygiene needs were met while in care:” It was alleged that on 05/12/2024, R1 was observed to “not have been bathed in days.” LPA interviewed both staff and residents related to hygiene needs. All persons interviewed stated that when a resident is on hospice, the hospice agency sends a shower/bath aide 2-3 times a week as ordered for the resident. As R1 was on hospice care as of 05/05/2024, hospice would have been responsible for bathing R1. Staff also indicated that they offer a sponge bath between scheduled showers, if the resident requires additional care. In the case of R1, R1 only resided at the facility for 9 days, however, staff interviewed believe hospice did shower R1 during that time. Although LPA was unable to interview R1, other residents interviewed felt their hygiene needs are met and had no concerns related to their shower/bathing needs. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Allegation: “Staff did not ensure that resident’s toileting needs were met while in care:” The complaint alleged that on 05/12/2024, R1 was observed to be “covered in feces.” LPA interviewed both staff and residents, who indicated residents that require incontinence care are checked every 2 hours and changed as needed during the day and night. During LPA’s visits, there were no observed incontinence odors present nor any indication that the residents’ toileting needs are not met. Residents felt the staff do a sufficient job checking on them and meeting their needs. LPA was unable to interview R1 related to the Report Continued on LIC 9099-C (p.4) allegation, as R1 was hospitalized as of 05/12/2024, prior to the complaint being filed. LPA confirmed that R1 passed away in the hospital. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. A copy of today’s report was provided.