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32 | The investigation revealed the following: In regards to the allegation that "Staff did not address a resident's change in medical condition in a timely manner," it is alleged that R1's health condition was declining prior to their hospitalization on 5/14/2026, which included sustaining falls, severe dehydration, and wounds on R1's heels and sacrum, and that this change in condition was not addressed by staff prior to R1's hospitalization. During interviews with the residents, none of them corroborated the allegation. LPA interviewed R2 who is the former roommate of R1, and they stated from their observations staff did address R1's change of condition in a timely manner. Other residents interviewed stated that from their experience, staff do assist residents who have a declining medical condition in a timely manner. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that they did not observe R1 having a drastic change of condition prior to their hospitalization, nor did they have any record of R1 sustaining any falls or having wounds or pressure injuries. Another staff interviewed also stated that they did not observe R1 have a decline in condition prior to hospitalization, and also was on hospice who checked on the condition of his skin for any wounds or injuries. Based on hospice visit notes obtained from Quality Hospice on 5/6/2026 and 5/13/2026, it notes that R1's skin was intact and did not receive wound care respectively.
In regards to the allegation that "Staff did not notify authorized representative of incident," it is alleged that R1 sustained falls at the facility, and that R1's family was not notified of these incident or their change of condition. During interviews with the residents, none of them corroborated the allegation. One resident stated that the facility has contacted their family in the past and stays in touch with them. Another resident interviewed stated they are unsure if staff contact authorized representatives of serious incidents. During interviews with staff, none of them corroborated the allegation. One staff interviewed stated that R1 did not sustain any falls while living at the facility, and therefore no falls were reported. Another staff interviewed also stated they had no record or recollection of R1 falling, however they did notify the family and the licensing agency of R1's hospitalization when it occurred. During review of the SIRs, LPA confirmed the facility did notify CCLD of R1's hospitalization and deaths as required per reporting requirements.
Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations 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.
Exit interview held, and a copy of this report was provided. |