complaint·December 8, 2022

3/10/2022 until their passing on 6/11/2022. An examination of R1’s death certificate showed the immediate cause of death as cardiac and respiratory arrest and unspecified severe protein calorie malnutrition. Outside source records revealed R1 had a primary terminal diagnosis of unspecified severe protein-calorie malnutrition, as well as other co-morbidities. Records show that R1’s overall health was declining, and they were transitioning to end-of-life stage. During R1’s hospice assessment, they reported poor appetite, minimal food intake, increased lethargy and frequent naps. Records reflect R1 was placed on hospice in order to address the protein calorie deficiency. Interviews also indicated that hospice provided education as requested explaining that facility and or hospice staff cannot force R1 to eat if they chose not to do so. R1’s hospice records contained information regarding the onset and treatment of pressure injuries. On the day of R1’s hospice assessment, records show R1 was diagnosed with a Stage I pressure injury to the coccyx. Records also reflect that, on 6/8/2022, hospice provider treated three wounds; closed forehead wound; an open Stage 2 pressure injury on R1’s coccyx and an unstageable and open pressure injury to R1’s left ankle. Hospice providers cleansed the Stage 2 wound with wound spray, applied gauze and a hydrocolloid dressing every five days or as needed for soilage or dislodgement until healed. The same procedure was completed for the unstageable wound on R1’s ankle. Hospice notes showed that R1 was turned and repositioned on right side and a low air loss (LAL) mattress was provided to prevent and treat pressure wounds. Additionally, R1 was provided bilateral injury boots and care staff was provided education on turning/repositioning and applying pressure wounds as tolerated. Records revealed that R1 received wound care by hospice and facility staff. As to the allegation that the facility did not assist R1 with incontinence needs, an outside source close to R1 reported their observations made during visits to the facility. The source stated that facility and hospice staff went above and beyond to clean and change R1’s brief, provide a skin protection cream and “bed sore” cream. Resident interviews provided no complaints in regard to toileting assistance and undergarment checks and changes. Facility memory care management stated that most memory care residents are checked and changed every two hours at minimum and more if needed. At the time of this investigation the facility was providing one-hour checks and changes to a bedridden resident. During a visit to the facility on 5/4/2022, LPA Rebecca Ruiz toured R1’s room, which is a studio apartment with a bathroom and kitchenette. LPA Ruiz observed the resident sitting in a recliner next to the bed in the bedroom watching television. Based on LPA Ruiz’ observations, R1 was responsive to LPA and the facility staff who accompanied the LPA. At one point, R1 asked what was going on. LPA Ruiz reportedly observed dark stains on the carpet around R1’s bed and where the carpet meets the wood flooring of the kitchenette. LPA Ruiz did not report the scent of urine or other malodorous odors in the room or bathroom. LPA Ruiz did not report observing insects or vermin. LPA observed that R1’s bathroom was clean and free of clutter. On 12/6/22, LPA Pena also visited and toured the resident memory care rooms and common area living area. LPA noticed the common area was neat, orderly well lit, contained numerous chairs and recliners and an entertainment center. LPA noted that the carpets were without spots or stains and there were no malodorous odors. LPA also visited the memory care unit resident rooms and found them kempt, orderly without noticeable foul odors. The floors in the resident rooms were a wood or laminate surface. LPA did not observe carpet in the resident rooms. LPA did not observe any evidence of insects or vermin. Residents and staff consistently reported that trash is removed from resident rooms each shift and a deep cleaning is done weekly. Staff advised that rooms also receive additionally deep cleaning as needed. The Department has investigated the allegations that staff neglect resulted in a resident’s malnourishment and sustaining of a pressure injury; staff did not assist a resident with incontinence needs; did not provide an odor-free facility; did not clean resident’s room or maintain the carpet or address the presence of vermin. Investigation revealed that R1 received hospice care which was directed to address R1’s end of life condition, including calorie malnutrition. R1’s hospice care plan was endorsed by physicians, R1’s DPOA and facility staff. Additionally, no evidence was obtained to support the physical plant allegations. Based on the totality of the information obtained during this investigation; there is insufficient evidence to support the aforementioned allegations occurred as reported. Therefore, the findings are determined to be Unsubstantiated. Although the allegations may have occurred or could be valid, there is not a preponderance of evidence to prove they occurred. An exit interview was conducted with Director Gephart and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) were provided and Director Gephart’s signature on this form confirms receipt of these reports.