complaint·September 13, 2023

Department staff interview with the Executive Director revealed that they are not aware of a fall occurring with C1 around the time frame alleged by the RP. LPA Nickolas was unable to interview C1 because they are deceased. LPA Nickolas' facility file review revealed that the facility's in-house notes document a fall with C1 several months before. LPA Nickolas' file review also revealed that C2 never resided at the facility. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #2 “Resident sustained pressure ulcers while in care”. The allegation alleged that C1 had bed sores on two (2) areas of their body. The allegation alleged that the stage of the sores was unknown. Department staff interview with S1 revealed that S1 acknowledged the sores, and hospice provided the facility instructions on rotating C1. Department staff interview with the Executive Director revealed that a hospice nurse noted the pressure wounds on July 21, 2020, but it was too early to stage them. The Executive Director stated that the hospice agency advised them that the pressure wounds were healing nicely. LPA Nickolas' interview with C1 revealed they could not be interviewed because they are deceased. LPA Nickolas' file review revealed that C1's hospice agency treated their pressure wounds with wound care specialists and nurses. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #3: “Resident sustained unexplained bruising while in care”. The allegation alleged that numerous clients had bruises on their bodies. LPA Nickolas’ interview with the Business Office Manager revealed that although they worked at the facility when this allegation was made, they do not remember. LPA Nickolas’ interview with several clients in care revealed that they could not provide any information about this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #4 "Staff did not provide water to residents". The allegation alleged that clients were observed sitting outside in the heat, and there was no water or cups for clients to have water. LPA Nickolas' interview with the Business Office Manager revealed that they denied this allegation. LPA Nickolas interviewed several clients in care. However, the clients interviewed were unable to provide answers to questions asked about this allegation. LPA Nickolas observed pitchers of ice water and cups outside when clients were outside and in the common areas of all five (5) Villas. LPA Nickolas also reviewed the facility's hydration policy and confirmed that the facility's staff are trained according to the hydration policy. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #5 “Staff did not provided resident with their own hygiene supplies”. The allegation alleged that the facility staff has one (1) hairbrush for eight (8) residents. The allegation alleged that the Executive Director needed to go and buy supplies. Department staff interview with the Executive Director revealed that the facility cannot order supplies due to billing issues with the vendor. The Executive Director stated that supplies are ordered through the sister company, and the facility had yet to go without supplies. Department staff interview with S2 revealed that the facility is having trouble with the supplier delivering supplies; therefore, the Executive Director is buying supplies. S2 stated the facility has enough supplies to care for residents. Department staff interview with staff #3 (S3) revealed that S3 confirmed the allegation. During a facility tour on August 7, 2023, LPA Nickolas’ observed that the facility has sufficient hygiene supplies to care for the residents in care. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #6 "Staff not meeting resident's needs". The allegation alleged that the facility cannot meet the needs of the clients because they are understaffed. LPA Nickolas' interview with the Wellness Coordinator revealed one (1) caregiver in every Villa, except the largest Villa has two (2) caregivers. LPA Nickolas' interview with the Business Office Manager revealed that although there are assigned caregivers to each Villa, the staff working at the facility is expected to assist the clients when needed. LPA Nickolas' interviews with clients in care revealed that some clients could participate in the interview process while others could not. The clients who participated in the interview expressed no concerns about residing at the facility. LPA Nickolas visited the facility three (3) times and conducted tours during each visit. LPA Nickolas' observed sufficient staffing to meet the client's needs. A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and copy of this report was provided.