Complaint·August 22, 2025

Documentation also shows that staff assessed R1’s mobility, encouraged transfers to a wheelchair, and educated R1 about the importance of repositioning to prevent further injury. Despite these efforts, R1 at times declined repositioning or participation in mobility activities. Hospice records from September 2024 confirm that nursing assessments found no pressure ulcers and that pressure injury prevention measures were reinforced. Interviews with facility staff and review of assessments demonstrate that staff followed R1’s care plan, provided incontinence care, and made timely notifications to family and healthcare providers regarding skin concerns. There is not preponderance of evidence that staff did not take reasonable steps to prevent pressure injuries; therefore, the allegation is UNSUBSTANTIATED. *************************************************************************************************************************** Allegation: Staff are retaining a resident who needs a higher level of care – The investigation into this allegation consisted of interviews and record reviews. A review of R1’s records shows that staff consistently monitored R1’s needs, communicated with family, and sought medical input when concerns arose. Care notes indicate that staff contacted R1’s physician and family regarding R1’s skin condition, offered daily assistance with transfers, and adjusted care plans in response to changes in R1’s condition. Documentation further shows that R1 was regularly assessed, including a semi-annual assessment on 8/27/24, which confirmed that R1’s care needs remained within the facility’s scope of services. When R1’s condition began to change, staff appropriately discussed the option of hospice and initiated a referral in coordination with R1, family, and the physician. Hospice services began providing additional support, and staff continued to assist R1 with meals, hygiene, repositioning, and supervision as needed. Interviews with facility staff confirmed that assessments are updated every six months or sooner if a change in condition occurs, and decisions about placement are made based on resident needs, physician input, and family involvement. Records also show that when family raised concerns about R1 needing a higher level of care, the facility offered options such as hospice and provided information on skilled nursing placement, while respecting R1’s wishes. Law enforcement also conducted a welfare check on R1 and found no concerns about neglect or improper care. Although R1’s health conditions require significant staff assistance, the evidence demonstrates that the facility continues to provide care within its licensed scope, with added support from hospice when appropriate. Therefore, the allegation is found to be UNSUBSTANTIATED . {LIC9099-2} Allegation: Staff do not assist resident with obtaining medical care – The investigation into this allegation consisted of interviews and record reviews. Records show that staff consistently monitored R1’s health condition and made multiple attempts to notify the physician and R1’s family about the “open sore” on R1’s skin. For example, on 7/12/24 staff faxed R1’s doctor requesting home health services, and on 7/13/24 staff contacted R1’s sibling after the doctor requested to examine the “sore”. Progress notes also show that staff followed up with the physician and R1’s family on several occasions throughout July and August 2024, asking R1’s sibling to schedule a doctor’s visit. On 8/28/24, the facility further assessed R1’s condition and contacted R1’s primary care provider to request a hospice referral. Hospice services were later initiated, and assessments by hospice staff confirmed that R1 was receiving appropriate care, including monitoring of skin, aspiration risk, and positioning. Interviews and assessment records also confirm that staff regularly encouraged R1 to get out of bed, reposition, and participate in activities, but R1 often refused. Staff nonetheless continued to offer assistance, followed physician orders, and communicated with R1’s responsible party and stepfather about medical needs. Documentation shows that police conducted a wellness check on 8/28/24, and R1 confirmed to officers that staff were caring for him appropriately. Therefore, while R1’s medical care was sometimes delayed due to the responsible party and family needing to coordinate doctor visits, the evidence demonstrates that facility staff made efforts to assist R1 with obtaining medical care. This complaint is determined to be UNSUBSTANTIATED . ****************************************************************************************************************** Allegation: Staff do not monitor resident for change in condition – The investigation into this allegation consisted of interviews and record reviews. A review of R1’s care notes shows that staff regularly documented R1’s health status and changes in condition. For example, on 7/12/24, staff noted an “open sore” and promptly faxed the doctor for home health orders. On multiple occasions afterward, staff followed up by contacting R1’s doctor and family members about the “sore” and documented their communications. Staff also continued to monitor and record R1’s condition, noting whether the “sore” was open, if R1 had complaints of pain, and when family had been informed. On 8/27/24 and 8/28/24, staff and supervisors assessed R1’s ability to transfer, feed themselves, and tolerate repositioning. When concerns were noted, the primary care physician was notified, and a hospice referral was requested. Documentation further shows that R1 was offered assistance with repositioning, but he sometimes refused. {LIC9099-3} Staff continued to monitor, reassess, and communicate changes to the family, physician, and administration. Additionally, hospice services were later initiated, and nursing notes confirm R1’s condition was being checked, and preventive care was reinforced. Interviews with the Administrator and Health and Wellness staff confirmed that residents are reassessed every six months and whenever there is a change of condition. Staff responsible for assessments are trained and licensed, and all assessments are reviewed by administration and corporate staff to ensure appropriate care. Records also show that police conducted a welfare check on R1 in August 2024, and R1 told officers that staff were taking care of them. Based on the review of care notes, medical records, staff interviews, and outside service documentation, there is no preponderance of evidence that staff do not monitor resident’s change in condition. Therefore, the allegation is UNSUBSTANTIATED. ********************************************************************************************************************** Allegation: Staff do not ensure that resident’s incontinence needs are met – The investigation into this allegation consisted of interviews and record reviews. Records show that staff regularly checked and changed R1, including documentation on 07/23/2024 noting that R1 was checked and changed with no complaints or pain observed. R1’s assessments and service plans also confirm that staff were responsible for providing full assistance with bowel and bladder care, including the use of a condom catheter and bed changes as needed. R1’s care notes further show that staff communicated with R1’s family and physician when concerns such as an open sore were observed, and staff requested medical follow-up and hospice evaluation to ensure R1’s health needs were addressed. Interviews with the administrator confirmed that staff consistently offered incontinence care, although R1 would at times refuse assistance. Additionally, hospice nurse notes dated September 2024 documented skin checks and reinforced pressure ulcer and incontinence care prevention, with no untreated pressure sores found. Based on the evidence gathered, there is no preponderance of evidence to support the claim that staff do not meet R1’s incontinence care needs. Therefore, the allegation is found to be UNSUBSTANTIATED. {LIC9099-4} Allegation: Staff do not assist resident with ambulation – The investigation into this allegation consisted of interviews and record reviews. Review of R1’s care notes shows that staff regularly offered assistance to R1, but R1 was often noted to refuse getting out of bed or into the wheelchair. Documentation reflects that staff monitored R1’s condition closely, communicated with R1’s family members, and sought medical support as needed when skin concerns were observed. R1’s care notes also indicate that staff attempted transfers with the assistance of two caregivers, in line with R1’s assessed needs, and that adjustments to the environment, such as bed placement, were discussed to better support safe ambulation and transfers. Facility records, including initial and semi-annual assessments, service agreements, and physician reports, consistently document that R1 required two-person assist for transfers and was non-ambulatory due to medical conditions, including paralysis from a stroke. Interviews with staff further confirmed that assistance was offered daily, though R1 sometimes declined. Per hospice care notes, hospice recommended wheelchair use during meals to prevent aspiration, reinforcing that staff were expected to support mobility to the extent possible. Based on the evidence gathered, there is no preponderance of evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED . ********************************************************************************************************************** Allegation: Staff do not ensure that resident’s showering needs are met – The investigation into this allegation consisted of interviews and record reviews. Records show that staff were responsible for assisting R1 with bathing, which included scheduled bed baths twice per week. R1’s assessments and service agreements documented that R1 required staff assistance with bathing and personal hygiene. R1’s progress notes also showed that staff regularly checked and changed R1, and offered assistance as needed. Although R1 was often noted to refuse getting out of bed or into the wheelchair, there is not enough evidence that staff did not provide care. Additionally, documentation shows staff continued to encourage R1, monitor R1’s condition, and communicate with R1’s responsible party and family members regarding R1’s health and care needs. Interviews further confirmed that staff were aware of R1’s care plan and provided assistance as outlined. Therefore, the allegation is UNSUBSTANTIATED. {LIC9099-5} Allegation: Staff do not ensure that resident’s dietary needs are met – The investigation into this allegation consisted of interviews and record reviews. A review of R1’s records, including the Physician’s Report dated 4/17/23, shows that R1 had a prescribed special diet of mechanical soft, high fiber. Facility assessments and service plans dated 8/31/22, 8/11/23, and 8/27/24 document that staff are responsible for setting up meals, providing adaptive equipment such as special plates and utensils, and assisting R1 as needed during mealtimes. R1’s care notes also show that R1 was able to feed themselves with adaptive devices but required supervision and occasional assistance when R1 became fatigued. Staff consistently offered meal assistance, and adjustments such as a blue plate that secures to the table and weighted utensils were made to support independence. Interviews and progress notes also confirmed that when R1 expressed difficulty with self-feeding, staff provided hands-on assistance to ensure R1 was able to eat safely. Additionally, hospice recommendations dated September 2024 further reinforced that R1 be positioned in the wheelchair during meals and be visually monitored to prevent aspiration. While R1 and family at times expressed concerns, the evidence shows that the facility staff provided meal support, supervision, and accommodations consistent with R1’s dietary needs and care plan. Based on information gathered, there is not enough evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED. Noted that an unsubstantiated finding means that although the allegation may have happened the preponderance of evidence does not prove it. No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report was provided. {LIC9099-6}