complaint·March 14, 2024

The investigation revealed the following: Allegation #1- Resident sustained pressure injuries while in care. The details of the complaint alleged that the facility did not regularly rotate the resident every two hours as ordered in the resident's hospice plan, causing the resident to develop multiple pressure injuries on the back, bottom, arms, and legs. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Resident sustained pressure injuries while in care because the facility failed to rotate the resident every two hours. All staff stated that the resident was turned every two hours and repositioned. S1 stated that “all staff have had in-service training in how to care for hospice residents and pressure injury care was provided to this resident. Also, the resident had a history of skin breakdown prior to moving into our facility as reported in the LIC602, dated 07/07/2022”. S2 stated that “the resident’s skin was brittle and bruised easily”. LPA reviewed the Turning and Repositioning logs and the Patient Visit Documentation log from hospice that corroborates their account that the facility was following the care plan for the resident. LPA reviewed the Physician’s report (LIC602) dated 07/07/2022, that reports the resident has a history of skin condition or breakdown and is very sensitive. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Resident sustained pressure injuries while in care. Residents stated that they did not have any problems with neglect from the facility. Based on interviews and records reviewed there is insufficient evidence to support the allegation that Resident sustained pressure injuries while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur because the facility failed to follow the hospice care plan for the resident, therefore the allegation is Unsubstantiated . Report continued on LIC9099-C Allegation # 2- Staff did not follow resident's hospice care plan. The details of the complaint alleged that the facility did not follow the hospice care plan for the resident that led to the resident developing pressure injuries. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not follow resident's hospice care plan. All staff stated that the resident was turned every two hours and repositioned, and that the facility was adhering to the resident’s care plan. LPA reviewed the Turning and Repositioning logs and the Patient Visit Documentation log from hospice that corroborates their account that the facility was following the care plan for the resident. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Staff did not follow resident's hospice care plan. Residents stated that they were happy with the care and supervision being provided to them. Based on interviews and records reviewed there is insufficient evidence to support the allegation that Staff did not follow residents’ hospice care plan. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation # 3- Staff did not meet resident's incontinence needs. The details of the complaint alleged that the facility did not change the residents’ diaper regularly. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not meet resident's incontinence needs. All staff stated that all residents are monitored for issues of incontinence every two hours and are changed as necessary throughout the day. Staff stated additionally that some are changed more often than others according to their need and that it is noted in the changing log. LPA reviewed the changing log and found that the facility was changing the resident regularly. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Staff did not meet resident's incontinence needs. Residents stated that the staff are attentive to their incontinence issues and are changed when needed. Report continued on LIC9099-C Based on interviews and records reviewed there is insufficient evidence to support the allegation that Staff did not meet resident's incontinence needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation # 4- Staff did not notify responsible party of resident's change in condition. The details of the complaint alleged that the facility did not notify the responsible party of a change in the resident’s condition. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not notify responsible party of resident's change in condition. All staff stated that when a resident has a change in their condition the family is notified along with the hospice agency, and their Primary Care Physician. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Staff did not notify responsible party of resident's change in condition. Residents stated that they are happy with the staff and the care that they are getting from the facility. Based on interviews there is insufficient evidence to support the allegation that Staff did not notify responsible party of resident's change in condition. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation # 5- Licensee does not maintain facility clean and sanitary. The details of the complaint alleged that the residents’ room was dusty and unclean. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Licensee does not maintain facility clean and sanitary. Staff stated that the facility is cleaned three times a day. At breakfast, lunch, and dinner. They state that they clean the room first, do the laundry, and clean other areas of the house throughout the day. Report continued on LIC9099-C LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Licensee does not maintain facility clean and sanitary. The residents stated that the facility is never dirty or unsanitary. LPA observed the facility to be clean and maintained in accordance with Title 22 regulations. Based on interviews and observations there is insufficient evidence to support the allegation that Licensee does not maintain facility clean and sanitary. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation # 6- Staff did not assist resident with grooming. The details of the complaint alleged that the facility failed to wash the resident's face, resulting in the resident contracting conjunctivitis in one of her eyes. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not assist resident with grooming. All staff state that the residents’ hygiene needs are taken care of daily. S2 stated “We groom and bathe in the morning and evening. Home health nursing assistant and caregivers are in charge of doing both. It depends on the time. When they’re not here we do it”. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Staff did not assist resident with grooming. Residents stated that the staff does assist with grooming and bathing and that they are happy with the care and supervision given. Based on interviews there is insufficient evidence to support the allegation that Staff did not assist resident with grooming. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation # 7- Staff did not assist resident with bathing. The details of the complaint alleged that the facility did not clean nor bathe the resident. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not assist resident with bathing. Report continued on LIC9099-C All staff stated that all residents are groomed, changed, and bathed daily and that all staff are responsive to the personal care needs of its residents. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Staff did not assist resident with bathing. Residents stated that the staff does assist them with grooming and bathing. The residents further stated that are happy with the care and supervision provided by the staff. Based on interviews there is insufficient evidence to support the allegation that Staff did not assist resident with bathing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No deficiencies were cited. An exit interview was conducted with Renel Cabral, Facility Manager, and a copy of this report was provided.