complaint·September 8, 2023

Regarding the allegation that: Facility staff did not seek timely medical attention for resident's pressure injuries. The investigation was conducted by the department and consisted of review of resident #1's file, including home health records, interviews with facility staff, and medical personnel who provided care to resident #1. The investigation revealed that home health records listed that resident #1 had no pressure injuries when discharged from home health upon the date of discharge from the facility. Health insurance medical records contradict this information and list that resident #1 had a stage 3 wound the day before transferring out of the facility. Health insurance confirmed that resident #1 was discovered with stage 3 wound, resident #1's daughter was informed resident #1 must be transferred out for higher level of care , and hospice care was scheduled for the following day. Interviews and documentation list that resident #1 was observed with a stage 2 wound while at the facility, but was receiving regular treatment/ wound care. On the day resident #1 was transferred out of the facility, transferring administrator advised that LVN assessment stated that resident #1 wounds were a stage 2. There was insufficient evidence that the facility did not seek timely medical attention. Regarding the allegation that: Facility staff hit resident #1 resulting in bruising, the investigation consisted of review of resident #1's file, review of medical records, and interviews with Administrator, and Staff #1 - Staff #3. 4 out of 4 staff interviewed stated that they have not observed any residents being hit by staff. Review of resident #1's flie, indicates that resident #1 was taking medication that can cause bruising. Regarding the allegation that : Facility staff did not provide resident with linens in good condition. The investigation consisted of tour of facility, including resident rooms, and interviews with Administrator and staff #1 - staff #3. LPA did not observe linens in poor condition during initial and subsequent tours of resident room(s). Administrator and staff interviewed, stated that resident family members bring their own linens to the facility, and they are laundered by facility staff. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview was conducted with Mr. Castillo, and copy of report was provided.