complaint·February 21, 2025

CONTINUED FROM FORM LIC9099 Resident R1 was admitted to the facility on July 14, 2020 from a skilled nursing facility, on the assisted living waiver. R1 had a primary diagnosis of muscular distrophy and was non-ambulatory and requiring the use of a Hoyer lift to assist with transfers and toileting care. R1 was admitted on hospice on June 3, 2021, changed hospice provider on July 28, 2021, was discharged from hospice and readmitted with a third provider on June 14, 2022. Per a death report submitted by the facility to the Department, R1 passed away using medical aid in dying at the facility on July 29, 2022. Regarding the allegation that Staff caused injury to resident , the following has been concluded: Based on interviews conducted and records reviewed, R1 required two-person assistance along with the use of a Hoyer lift to transfer from the bed to her wheelchair as well as to receive toileting care. At the time of the incident reported, R1 was admitted onto hospice care and receiving assistance from a hospice bath aide three times a week. Per a review of hospice records, there were recorded instances of lower limb and feet swelling as well as one instance of toe debridement being required. There is however no evidence that the injuries were related to negligence on behalf of staff members. Regarding the allegation that Staff handle resident in a rough manner , the following has been concluded: Based on records reviewed and interviews conducted, the complexity of transfers for resident R1 was evidenced, however there was insufficient proof corroborating the allegation. Other concerns reported by R1 to hospice staff and local law enforcement also failed to yield any corroborating evidence. Regarding the allegation that Staff failed to provide adequate transportation for resident(s) , the following has been concluded: Due to R1's specific needs, the facility courtesy van could not be utilized, however transportation alternatives in the form of vouchers were provided to alleviate worries of cost expressed by the resident. Based on the present investigation, the three allegations are found to be Unsubstantiated, meaning that although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.