complaint·May 28, 2025

they are checking on their residents every two (2) hours to change a resident if needed, to rotate a resident or if resident need assistance. Interviews with eight (8) of eight (8) staff indicated that there's no incident at the facility that they neglected R1, and they did not prevent R1 from developing pressure injury. Records review revealed that R1's on hospice care and receiving wound care. Interview with R1 hospice nurse on 05/22/2025 revealed that it was not due to staff neglect because R1 developed pressure injury but due to R1's change of condition and gradually decline in addition to R1 refusing care and severe agitation. Moreover, R1 hospice nurse stated that due to R1 declining health condition that started few weeks ago, they put R1 on comfort care medications. The second allegation indicates that staff did not ensure resident’s room was free from odors. During the investigation, LPA Brown was not able to obtain sufficient evidence to corroborate the allegation. Four (4) of four (4) residents interviewed reported that staff at the facility clean their room every week and they stated that all staff at the facility ensure that their room was free from odors. LPA Brown unable to interview R1 as R1 unable to answer LPA Brown's questions. Interviews with nine (9) of nine (9) staff indicated that housekeeping staff are cleaning residents’ rooms once a week and care staff make sure that trash, food trays, leftover food are picked up daily to ensure that residents’ rooms are free from odors. Nine (9) of nine (9) staff interviewed said that there's no incident at the facility that they did not ensure that R1's room was free from odors. Records review showed that all housekeeping staff have a schedule to clean all residents’ rooms weekly. During the facility visit on 05/22/2025, LPA Brown observed that R1's room was clean and free from odors. The third allegation indicates that staff did not ensure that a resident is using clean linen at all times. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with four (4) of four (4) residents indicated that all staff at the facility make sure that they always have clean linens. LPA Brown unable to interview R1 as R1 unable to answer LPA Brown's questions. Nine (9) of nine (9) staff reported that there's no incident at the facility that they did not ensure that their residents are using clean linens. Interviews with nine (9) of nine (9) staff revealed that they are changing their residents’ linens weekly and if they observed that a resident linen is dirty, they immediately change it. Nine (9) of nine (9) staff denied not ensuring that R1 always has clean linen. During the facility visit on 05/22/2025, LPA Brown observed R1 linens clean. The fourth allegation indicates staff did not adequately assist resident with care needs. During the investigation, LPA Brown was not able to obtain sufficient evidence **Continuation in LIC9099C** to corroborate the allegation. Four (4) of four (4) residents interviewed reported that all staff at the facility are adequately assisting them with their care needs as all staff are regularly checking on them if they need assistance and assisting them with their activities of daily living (ADLs). Interviews with four (4) of four (4) residents revealed that staff at the facility are meeting their care needs. LPA Brown unable to interview R1 as R1 unable to answer LPA Brown's questions. Interviews with eight (8) of eight (8) staff indicated that they all make sure that they are adequately assisting all their residents to meet their care needs. Eight (8) of eight (8) staff interviewed reported that there's no incident at the facility that staff did not adequately assist R1 with R1's care needs. An interview with R1 hospice nurse on 05/22/2025 indicated that all staff at the facility are providing the appropriate care for R1 to meet R1's needs. During the facility visit on 05/22/2025, LPA Brown observed staff at the facility working with R1 hospice nurse to ensure that they are adequately assisting R1 to meet R1's needs. Therefore, based on the evidence obtained during tLPA Brown's investigation, there is insufficient evidence to prove that staff did not prevent resident from developing a pressure injury (Allegation #1), staff did not ensure resident’s room was free from odors (Allegation #2), staff did not ensure that a resident is using clean linen at all times (Allegation #3), staff did not adequately assist resident with care needs (Allegation #4) are UNSUBSTANTIATED at this time. Although the allegation of staff did not prevent resident from developing a pressure injury (Allegation #1), staff did not ensure resident’s room was free from odors (Allegation #2), staff did not ensure that a resident is using clean linen at all times (Allegation #3), staff did not adequately assist resident with care needs (Allegation #4) 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 at this time. An exit interview was conducted where this report (LIC9099), was discussed and provided to ED Karen Roper.