LPA Wesley requested a copy of the staff and resident roster, emergency identification page, admission agreement, physicians report for resident #1, care plan from the home health agency, appraisal needs and services plan, and other documents for resident #1. There were no immediate health and safety concerns observed.

The investigation consisted of reviewing pertinent medical records of R1, Incidents reports, Interviewing four (4) staff and three (3) current residents. LPA was not able to interview three (3) other current residents during visit. LPA made attempts to interview former staff who worked during the time of the allegations. Only one (1) former staff was able to answer questions. One (1) former staff was deceased, and the other staff could not recall the resident or refused to answer questions. LPA interviewed one (1) witness W#1 who is family member.

The investigation revealed:

Allegation: Questionable death. It is alleged that facility was responsible for R1 death.

LPA interviewed four (4) staff and three (3) residents and Four (4) of four (4) staff denied the allegation. Three (3) of three (3) residents could not corroborate the allegation. According to documents reviewed by the department, resident was sent to hospital by facility on 01/09/2022 and died on 01/13/2022. The resident was sent to the hospital by facility and was alive for 4 days while at the hospital, the resident died at the hospital. There is no evidence that facility caused resident’s death.

Allegation: Management accepted resident who required a higher level of care. It is alleged that facility accepted resident who required higher level of care.

LPA interviewed four (4) staff and all four (4) staff denied the allegation. Three (3) of three (3) residents could not corroborate the allegation. S2 stated that resident would not have been accepted if resident required a higher level of care. On 11/24/2021, according to skilled nursing facility (SNF) discharge summary, resident was discharged from SNF and placed at the facility to meet resident’s needs. The resident was at a higher level of care when discharged to facility by SNF on 11/24/2021. According to resident’s Physicians report dated 11/23/2021, there is nothing in the report that indicates that resident cannot be cared for at the facility. There is not enough evidence to substantiate

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LPA interviewed four (4) staff and Three (3) residents and Four (4) of four (4) staff denied the allegation. Three (3) of three (3) residents could not corroborate the allegation.

Staff stated that oxygen was on a as needed basis and was given to resident when resident required it. The department reviewed a referral by Expert Senior Placement which reported that resident is on 2L of oxygen soon to be room air. Physicians report dated 11/23/2021 under Medication Management section (e) states that resident need 2L min H20 – PRN. Documentation reviewed indicated that oxygen was to be supplied by home health agency. There is not enough evidence to substantiate this allegation.

Allegation: Staff did not prevent a resident fall. It is alleged that resident suffered an un-witnessed fall on 12/27/2021 and staff should’ve prevented the fall.

LPA interviewed four (4) staff and three (3) residents and Four (4) of four (4) staff denied the allegation. Three (3) of three (3) residents could not corroborate the allegation. According to incident report submitted by the facility, resident stated that resident was reaching for resident table and fell. Resident was taken to emergency room and x-rays came back negative. According to report, responsible party was notified. Resident’s doctor decided to keep resident for a few days for observation. The facility could not have prevented the fall because resident did not alert staff about reaching for resident table. According to staff , resident had a bell and intercom system was in place for client to alert staff. There is not sufficient evidence that staff may have been able to prevent residents’ fall.

Allegation: Staff did not assist the resident with getting dressed when brought back to facility from hospital. It is alleged that when resident returned from hospital stay, that resident was placed in room naked and facility staff did not assist resident..

LPA interviewed four (4) staff and Three (3) residents and Four (4) of four (4) staff denied the allegation. Three (3) of three (3) residents could not corroborate the allegation.

Sometime around December 2021, resident returned from hospital visit and was alleged by W1 to have arrived with no clothes and left like that by the facility. Staff reported that resident arrived in hospital gown and was left in the gown since resident remained in bed. There were conflicting accounts of how resident arrived from hospital. W1 reported resident arrived with gown from hospital and later reported to LPA that resident arrived naked. There is not sufficient evidence that to substantiate this allegation.

LPA interviewed four (4) staff and Three (3) residents and four (4) of four (4) staff denied the allegation. Three (3) of three (3) residents could not corroborate the allegation. LPA asked W1 to provide dates that calls were not returned, and W1 stated he could not recall the dates. All staff stated that calls are promptly returned, and responsible parties are kept always informed of their loved one. There is not enough evidence to substantiate this allegation.

Allegation: Staff did not call resident's doctor to tell him resident was not eating. It is alleged that resident was not eating, and resident’s doctor was not notified.

LPA interviewed four (4) staff and three (3) residents and Four (4) of four (4) staff denied the allegation. Three (3) of three (3) residents could not corroborate the allegation. LPA reviewed documentation that resident’s doctor was aware that resident did not have good appetite and had been prescribed medication to increase appetite for some time prior to arriving at facility. There is no evidence to substantiate this allegation.

Allegation: Staff did not give authorized representative an assessment on how the resident was doing. It is alleged that facility was not being forthcoming about resident’s condition.

LPA interviewed four (4) staff and three (3) residents and Four (4) of four (4) staff denied the allegation. Three (3) of three (3) residents could not corroborate the allegation. Staff stated that they always keep responsible party aware of resident’s condition. W1 stated that W1 would call, or text facility and facility staff would respond saying the resident was fine. W1 did not provide any evidence for this allegation. There is not enough evidence to substantiate this allegation.

Allegation: Staff did not notify doctor that the resident was in pain. It is alleged that resident’s doctor was not notified when resident was in pain.

LPA interviewed four (4) staff and three (3) residents and four (4) of four (4) staff denied the allegation. Three (3) of three (3) residents do not corroborate the allegation. LPA reviewed doctor’s orders for resident, and it is documented that resident had already been prescribed medication for pain by resident’s doctor and doctor was aware that resident suffered from pain. Staff stated that resident never complained about pain to any staff. There is not enough evidence to substantiate this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.