complaint·July 28, 2023

The investigation revealed the following: Allegation: Staff did not address resident’s change in condition On 7/28/2023 at 9am LPA Shirley reviewed facility files. During file review, LPA found that Resident 1 (R1) was admitted to Fortitude Hospice Inc. on 5/16/2023. LPA S Per R1’s hospice folder, facility can send resident to the hospital if needed. LPA Shirley reviewed facility sign in sheet and noted that on 6/4/23 at 2:28pm and 8:30pm there are sign ins from Fortitude Hospice Inc to visit R1. It is alleged that R1’s condition changed, and facility staff did not appropriately address the change. On 7/28/2023 From 9am to 1pm LPA Shirley interviewed Staff 1-Staff 2 (S1 - S2), Resident 1-Resident 3(R1-R3) and Witness 1-Witness 3 (W1-W3) and learned the following. On June 4, 2023, S1 noted that R1 was having difficulties breathing and her oxygen levels were low, so the facility contacted hospice around 12:30pm. Fortitude Hospice recommended a treatment and stated they would send one of their staff to assess R1. Facility staff completed treatment given to them by hospice and at 2:20pm hospice staff arrived and R1 was stabilized. Early evening, R1’s condition changed again and S1 called hospice agency at 7:19pm, where she and the hospice staff conducted a facetime call regarding residents’ condition. Per W2, R1’s family contacted at this time and Fortitude Hospice recommended continuing care treatment for R1 instead of hospitalization. Family agreed and W3 arrived at facility at 8:30pm for continuing care treatment. R1 passed at 10:43pm. Based on information gathered, the department did not find sufficient evidence to support allegations " Staff did not address resident’s change in condition.” An exit interview was conducted and a copy of the LIC 9099 was provided to Administrator Rosemarie Famison.