Interviewed Administrator and Assistant administrator denied the allegation. They stated that both residents were under the same hospice care: “Comfort Hospice Care”, and they were instructed to call hospice 24/7 for any reports/significant changes, which they did. Hospice nurse visited residents twice a week and staff always contact / report to the hospice when they noticed any significant changes on R1 and R2. LPA obtained and reviewed Hospice notes for R1 and R2. For R2 it said that at the time of nurse visits on 2/1/2019 ”vital signs are low but are still within normal parameters including blood pressure”. R2’s daughter requested doctor’s visit and the visit scheduled at the next day. Hospice MD was notified and obtained new order for R2. Administrator stated that R1 was incontinent and when staff changed the resident, they never noticed that R1 was bleeding. Review of hospice agency documentation shows that R1 never had vaginal bleeding. Hospice documents showed that R1 started continuous care (round a clock nursing supervision) from 5/28/2019 – 5/30/2019 because of R1’s last stage of their life. Patients/residents declining and last stage of their life they always have moaning and gurgling noises. The gurgling noise is due to patient unable to swallow their saliva. R1 admitted under Comfort Hospice Care as of 04/08/2019. Per Register Nurse's Initial evaluation and head to toe assessment patient did not have any wounds but had very sensitive skin and on high risk for open wounds. R1 transferred to facility with DTI (Deep Tissue Injury) which is very common for patients with CVA (cerebral vascular accident) diagnosis. Patient never had a pressure ulcer not in the hospital (from R1 was transfered to the facility), not at the facility. On 05/24/2019 report from visiting nurse said that R1’s Left Foot Deep tissue injury has opened and is now a Stage II Left foot pressure ulcer, which is very common with bed bound patients /residents. Wound has been treated appropriately and reported to doctor. For the pain R1 was prescribed Tylenol, Tramadol and at the letter time Morphine for lot of pain by the Hospice Doctor.

During interviews, Administrator and Assistant Administrator stated that staff have never handled residents in a rough manner. They have never witnessed that staff handle residents in a rough manner. They stated that staff treat residents with dignity and respect. Administrator has never received any complaints from residents and staff that S3 has handled R1 in a rough manner or aggressively feed R1 which caused resident to choke. Interviewed Administrator and Assistant Administrator indicated if residents could feed themselves, staff would let residents eat at their regular time and will never force them. Staff will help / assist residents if it’s necessary. LPA observed on the hospice notes says that assistance needed for R1 with feeding. At the lunch time, during the visit LPA didn’t observe that staff force feeding residents. During the visit, LPA was informed that S3 is no longer employed at the facility. LPA was unable to contact S3 for an interview.

Regarding the allegation: Staff restrained resident. It was alleged that R1 had a gait belt on her wheelchair and R1 was dressed over the gait belt which was against R1 skin. R2’s daughter came to visit and found armchair furniture all around R2’s bed.

Administrator and Assistant Administrator denied the allegation. The use of restrain were never use with any of the residents. In or out of the bed. They never used armchairs around of resident’s bed to restrained them. Administrator stated that R1 had a gait belt on their wheelchair to prevent falls not for restraint resident. During the record review LPA observed the gait belt that R1 used was prescribed by the doctor for resident safety and fall prevention. On Hospice notes were nothing indicated about R1's skin damaged / injury /wounds because of gain belt against the skin. Administrator also indicated R1’s family members were acknowledged the gait belt.The gait belt used around the wheelchair for safety issues.

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Interviewed Administrator and Assistant Administrator denied the allegation. Wheelchair pedals are always attached to resident wheelchair, unless PT (Physical Therapist) moves and walk around and to prevent injury we removed, but we notified the doctor. Administrator and assistant administrator never witnessed that caregivers “pop wheelies” to maneuver resident. Facility staff very careful when they are assisting residents on the wheelchair. At the time of visit LPA observed residents on the wheelchair in the living room. All wheelchairs have a foot pedals and caregivers handled residents very carefully.

Based on statements and interviews conducted, review of residents 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.