complaint·July 17, 2025

healthcare progress notes/summary from Brittany House & Shoreline Healthcare Center dated 4/28/2023, and Specialty Hospice Care records dated 8/5/2024 - 10/11/2024. LPA also conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - 8 (R1–R8), Witness 1(W1) and attempted to interview Resident 9 (R9) who no longer resides at the facility. Investigation revealed the following: #1- Allegation: Resident sustained an unstageable pressure injury due to lack of care from staff. On 5/12/2025, at 11:00 AM, LPA Allen conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members denied knowing if R1 suffered from a pressure wound or whether an outside agency was providing wound care. LPA interviewed Residents 1 - 8 (R1–R8). Of the 8 residents, 2 stated that they do not have any pressure injuries, The remaining 6 residents were unable to engage in a clear conversation, and LPA did not observe any visible pressure injuries on residents. W1 stated there was a pressure injury caused due to lack of care but could not provide evidence to corroborate the allegation. LPA reviewed R9’s facility file and found hospice records from Specialty Hospice confirming services were provided 2x/week from 06/14/2024 - 10/11/2024, and The Wound Pros provided care 1x/week from 8/5/2024- 10/11/2024. The needs and service plan dated 4/28/2023 - 10/16/2023 does not indicate the presence of a pressure injury. LPA could not obtain sufficient evidence to substantiate that R9 sustained a pressure injury due to a lack of care by facility staff. #2- Allegation: Staff did not provide resident's medication as prescribed On 5/12/2025, LPA conducted interviews with Staff 1- Staff 10 (S1-S10), of those interviewed, 10 out of 10 stated that all residents are given their medications as prescribed by their physicians. On 5/12/2025 LPA reviewed R9’s file and found no records to verify whether R9 received their medication as prescribed. On 5/12/2025 and 5/22/2025 the Medication Administration Records (MARS) could not be provided for R9 therefore, LPA was unable to verify if their medications were given or not. LPA interviewed Residents 1 – Resident 8 (R1–R8) of the 8 residents, 2 stated they get their medications daily the remaining 6 residents were unable to engage in a clear conversation. #3- Allegation: Staff did not provide daily activities for residents. On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that residents are provided with daily activities and showed a schedule of activities posted on the wall and provided a printed copy. LPA interviewed Residents 1 - 8 (R1–R8). Of the 8 residents, 2 stated they have engaged in daily activities, while the remaining 6 residents were unable to engage in a clear conversation. On 5/12/2025, during a facility tour, LPA observed the activity director conducting rounds throughout the premises, actively facilitating various activities with the residents. These included morning exercise, coloring, nail painting, and arts & crafts. Additionally, a monthly activity schedule dated September 2024, outlining events from 9:15 AM to 6:00 PM, was available for review. #4- Allegation: Staff did not ensure that residents were adequately fed On May 12, 2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that all residents in care receive three meals daily, including snacks, and that meals are determined based on their dietary needs. S10 mentioned that R9 was on a fortified mechanical soft meal and thin liquids, but specific dates could not be provided. LPA reviewed R9’s physician's report dated 4/27/2023 and Specialty Hospice Care records dated 6/14/2024, which confirmed that R9 was on a fortified mechanical soft meal and thin liquids diet. Additionally, LPA interviewed Residents 1 - 8 (R1–R8). Of the 8 residents, 2 stated they receive three meals daily, while the remaining 6 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed residents having meals, including a balanced breakfast of bacon, eggs, and oatmeal, followed by lunch consisting of baked pork chops, mashed potatoes, mixed vegetables, cornbread, water, and juice. Continued On May 22, 2025, LPA again observed residents consuming a balanced lunch, which included tuna casserole, green beans, salad, cornbread, juice, and water. LPA also observed menus that coincided with the meals being provided each day. During a tour of the facility kitchen, LPA noted a five-day supply of perishable food and a seven-day supply of non-perishable food items. The kitchen appeared clean, and no health or safety concerns were observed during the visit. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated . An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.