complaint·May 20, 2025

On 11/06/24 LPA toured the facility at 1:30 p.m., conducted a medication review at 1:35 p.m., interviewed a former staff member, Staff #1 (S1) at 1:45 p.m., and conducted a record review of pertinent records, including but not limited to wound care notes and cash ledgers at 2:00 p.m. LPA Reed requested additional records for review. Prior to this visit on 02/04/2025, 03/20/24 and 04/06/3025, LPA Reed reviewed all documents received from the facility and other medical providers and conducted interview with the representatives from the health care agencies assisting R1. It was alleged the facility retained resident(s) with severe pressure injuries. Interview with the administrator and other staff revealed that currently no residents have prohibited health conditions. Administrator verified that between June 2024 and September 2024, while under hospice care Resident #1 (R1) developed Stage 3 and/or Unstageable Pressure Injuries, and the care was provided by the hospice agency. Interviews with seven (07) other residents revealed no issues with pressure injuries. A review of records revealed that R1 started receiving Hospice services as of 06/11/2024 for other health conditions. As per hospice records the Pressure Injuries noted on R1s skin were staged as Stage 2. Although, the hospice records did not disclose any changes of R1s pressure injuries, on 06/26/24, the wound care specialists attended R1 and they identify Sacrococcygeal pressure injury at Stage 3 and an Unstageable pressure injury on left heel. Wound care specialists provided wound care between 06/26/24 and 09/11/24 and condition of Sacrococcygeal Pressure Injury was not improved. On 09/11/24, while R1 continued to retain at the facility, R1’s hospice services and wound care assistance were interrupted. Between on 09/17/24 and 09/27/24 R1 was attended by the home health nurse, to provide a wound care. A treatment was unsuccessful and on 09/27/25, R1 was sent to the hospital due to infected wound. The information revealed from interviews and record review verified that the facility continued to retain R1 with prohibited health condition upon interruption of Hospice services. Therefore, the allegation is SUBSTANTIATED at this time. Although the allegation is substantiated, no citation will be issued as the facility was cited on 03/20/25, while LPA addressed other issues unrelated to the complaint. Exit interview conducted. Copy of report provided. Interviews with seven (07) out of seven (07) residents revealed no occurrences of physical abuse or rough handling by staff. Interviews with staff and the administrator revealed no staff handle residents roughly or abuse residents. During a facility tour on 11/06/24, LPA observed staff handling residents gently and with respect. Based on interviews and observations, there was no evidence corroborating the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff steal residents’ medications" it was alleged staff steal bottles of resident medication. Interviews with seven (07) out of seven (07) residents revealed no occurrences of missing or stolen medications. Residents confirmed they receive all medications in the right doses. Interviews with staff and the administrator revealed no staff steal medications and no residents are missing any medications. Medication review revealed three (03) out of three (03) residents’ medications were accounted for. None were missing or stolen. Based on medication review and interviews, staff do not steal residents’ medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff steal residents money" it was alleged staff members steal residents’ monthly income. Interviews with seven (07) out of seven (07) residents revealed no occurrences of stolen or missing money. Residents interviewed who receive P&I money had no problems with accessing their money. Interviews with staff revealed no reports of staff stealing resident money. Interview with the administrator revealed all resident money is recorded on the internal P&I ledger. Review of P&I ledgers on 11/06/24 at 2:00 p.m. revealed resident money was accounted for and none was missing or stolen. Based on record review and interviews, staff do not steal residents’ money. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff sexually abused residents in care" it was alleged that S1 sexually abused Resident #1 (R1) and Resident #2 (R2). Record review of the resident list revealed R1 and R2 were not currently residents. Interview with S1 revealed they have never abused R1 or R2 and had good relationships with both. R1 and R2 were all unavailable for interviews. Interviews with seven (07) out of seven (07) residents revealed no occurrences of sexual abuse by staff. Residents interviewed stated staff were fine. Interviews with staff and the administrator revealed no evidence of sexual abuse. Based on interviews, no residents were sexually abused by staff. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.