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32 | It was alleged that the facility was preventing Resident #1 (R1) from receiving gifts, specifically multiple flower deliveries and a book. LPA interviewed four (4) facility staff who stated that staff will bring any deliveries for R1 to their room and R1 has the choice to receive or decline. Two (2) staff members stated that flowers were delivered to R1 but they were unsure if R1 kept them. One (1) staff member stated that R1 received a book and kept it. LPA interviewed R1 and three (3) witnesses who all confirmed that R1 received the flowers but did not wish to keep them so they gave the flowers away. R1 and witnesses also confirmed that facility staff bring deliveries to R1's room and R1 decides to accept or decline. LPA reviewed photographic evidence confirming the flower delivery to R1. LPA reviewed the facility’s delivery logs and observed multiple package deliveries to R1. R1 and R1’s responsible parties interviewed had no concerns of R1 being prevented from receiving gifts or deliveries. Based on interview and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff are not allowing resident to receive gifts while in care” is deemed UNSUBSTANTIATED at this time.
It was further alleged that R1 sustained multiple pressure injuries on their legs and heels possibly due to staff neglect. LPA reviewed records and observed that R1 was hospitalized from 12/22/2025-01/02/2026. LPA interviewed staff, R1, and witnesses who stated that R1 did not develop any pressure injuries under the care of the facility. All interviews confirmed that R1 did have some discoloration on their heel, but that this was a pre-existing condition prior to R1’s admission to the facility and not an open wound. Interviews also confirmed that during R1’s hospital stay, R1 developed minor redness/blister on their back but R1’s condition began improving after hospital discharge. LPA did not observe any open wounds on R1 during the initial visit. LPA was unable to observe R1 during today’s visit as R1 no longer resides at the facility. Record review of R1's care plan, physician's report, and appraisals contained no evidence of R1 developing pressure injuries while at the facility. Based on interview, observation, and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not prevent resident from developing pressure ulcers” is deemed UNSUBSTANTIATED at this time.
No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
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