Complaint·November 17, 2023

resident’s cause of death was respiratory failure and end stage COPD. The resident’s records indicate that on 06/04/2022, the resident developed a Stage 1 pressure injury on the sacral area. Wound care was requested. On 06/11/2022, records show the resident began receiving hospice care. On 06/17/2022, hospice provider conducted an initial nurse visit with the resident and noted open wound between resident’s glutei. Notes stated wound care was prescribed every time the resident was toileted. The resident was given a gel cushion for sitting. A 06/20/2022, progress note entry stated, the resident “was repositioned every two hours.” The complaint alleged insufficient staffing did not meet residents’ needs. The complaint stated that the facility used "agency" staff that were not trained to provide care and supervision to bedridden residents. Interviews with facility management and a review of records did not provide corroboration for this claim. Staff interviews revealed that unscheduled absences, such as sick leave, cause incidental staff shortages. To address the shortages, the facility utilizes agency staffing. Interviews and records did not reveal support for the allegation that the facility has insufficient staffing. Resident interviews yielded no complaints about lapses in service by staff. It was claimed that staff mismanaged resident medications. A sample of six staff training records and nine resident medication records were reviewed. All staff training records included the completion of medication training. None of the resident’s medication records showed evidence of medication mishandling or errors. It was alleged staff neglect resulted in resident urinary tract infections. It was alleged a resident was left in soiled clothing for extended periods. Records indicate that the resident was nonambulatory due to physical and mental conditions. The resident’s records noted lower extremity cellulitis. Progress notes showed the resident received consistent wound care. The resident’s care plan included dressing changes, weekly debridement as needed and home health nurse visits three times per week to perform dressing changes. Staff interviews did not reveal support for the allegation. Progress notes showed that incoming staff make sure residents receive clothing changes on prior shifts and change clothing as needed. Resident interviews did not reveal complaints about clothing changes. An allegation that the facility had an infestation of rodents and roaches was investigated. Resident interviews offered no information to support the allegation. Staff interviews noted incidental pest sightings but denied the presence of an infestation. Facility management provided LPA with copies of pest control service reports, as current as 6/1/22. The targeted pests were roaches. The 6/1/22 service report showed the facility was inspected for rodent activity as well. The report stated that no evidence of rodent activity was observed. Report stated, “no significant cockroach activity. Four (4) roaches were flushed in dishwashing area.” Another allegation was that neglect resulted in resident falls. Resident records were reviewed and noted numerous falls, mostly unwitnessed. The records did not indicate injuries occurred as a result of the falls. The resident’s documented behavior pattern showed they would become agitated and purposely slide off their bed onto the ground. Strategies such as giving the resident a lower bed, and approved bed rails were implemented to reduce falls. It was alleged that residents sustain body rashes due to neglect. A resident was identified and interviewed regarding this allegation. According to the resident, they developed a fungal infection over various parts of their body. The resident said the community physician provided medicated cream and the condition was just about gone. The resident also received referral to a dermatologist. The resident said the facility was very helpful and responsive. The Department has investigated the aforementioned allegations. Based on interviews and record reviews the investigation yielded insufficient evidence to support the allegations. The preponderance of evidence standard was not met; therefore, the allegations are deemed Unsubstantiated. An exit interview was conducted with Disha Hall, Executive Director, Hall and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to Ms. Hall at the conclusion of the visit.