On 05/14/2025, at 11:30 A.M., Health and Wellness Director Tamera Gant and LPA Bunker toured the facility buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit.

On 05/14/2025, between 9:30 a.m. and 12:30 p.m., and on 05/28/2025, between 9:30 a.m. and 3:30 p.m., LPA Pamela Bunker conducted interviews with staff members #1–#3 (S1–S3). On 05/14/2025, at 12:30 p.m., LPA Bunker conducted interviews with resident #1 (R1) and witness #1-#2 (W1-W2).

The investigation revealed the following.
Allegation: Staff neglect resulted in the resident developing a pressure injury.
It was alleged that staff neglect resulted in the resident developing a pressure injury. Staff members #1–3 (S1–S3) interviewed stated that R1 never disclosed a pressure injury. 3 out of 3 staff members stated they did not know about any pressure injury to R1's body. The facility was not required to bathe R1; however, the facility assisted, and R1 was bathed by his home health agency. On 08/27/2024, R1 was ambulatory until R1 sustained a fall while on a visit with his family at church.

R1 required rehabilitation, which R1 received outside the facility. On 09/27/2024, Records indicate R1 developed a pressure injury while at the rehabilitation center. Studio Royale sent a representative to the rehabilitation center for evaluation before R1 returned to Studio Royale. The rehabilitation center made note that R1 was able to return to Studio Royale; however, upon R1's return to Studio Royale, it was noted that the pressure injury had not been resolved. The facility made several attempts to provide many options for R1 and communicated these options to his power of attorney (POA) with no results. Upon a scheduled doctor’s appointment, R1 was subsequently admitted to the hospital for the pressure injury. The facility staff were interviewed and denied any neglect or lack of supervision. The Department found no evidence that R1's pressure injury manifested while at the facility.

See continued LIC9099-C page 2.

On August 27, 2024, R1 was hospitalized after falling at church. From August 27, 2024, to May 3, 2025, R1 resided in a Skilled Nursing Facility (SNF). Guardian Rehabilitation Hospital diagnosed R1 with an unstable pressure ulcer on the sacral area on the following dates: September 17, 2024, October 15, 2024, November 5, 2024, December 17, 2024, January 5, 2025, February 6, 2025, February 20, 2025, February 27, 2025, and March 6, 2025 pressure ulcer of sacral region, stage 4. On March 28, 2025, R1 had a stage 2 wound on the coccyx. On May 6, 2025, following discharge from the hospital, Ideal Home Health Care assessed R1 and identified a stage 4 wound at the facility. The Department reviewed R1 records and confirmed the documentation.

Allegation: Staff retained the resident requiring a higher level of care.

On March 28, 2025, R1’s Case Manager reported that R1 had a Stage 2 wound. On May 3, 2025, when R1 returned from the hospital, the Home Health nurse assessed the wound as Stage 4. R1’s care needs increased significantly, and R1 required a higher level of care. That same day, R1 was sent back to the hospital and later returned to the facility. S1 and S2 stated they attempted to arrange a higher level of care, but R1 refused both transfer and hospice services. S1–S2 stated they would never discharge R1 without securing appropriate placement. S1–S3 also stated that they informed R1’s Power of Attorney (POA) that R1 needed a higher level of care.

On May 14, 2025, the Department interviewed R1. R1 did not mention requiring a higher level of care and repeatedly questioned the purpose of the interview before walking away. See continued LIC9099-C page 4.

On May 14, 2025, at 11:50 a.m., the Department interviewed Witnesses #1 and #2 (W1–W2) together via telephone. W1–W2 stated that staff retained R1 despite R1’s increased care needs. However, they confirmed that on May 8, 2025, a meeting occurred with Studio Royale, R1’s family, R1’s attorney, and the Ombudsman. During that meeting, the family requested additional time to find a suitable placement for R1, and the facility agreed to take no further action until after a follow-up discussion scheduled for May 9, 2025.

2 out of 3 staff members stated that staff communicated R1's care needs with R1’s POA. 3 out of 3 staff members denied the allegation.

On August 7, 2024, R1 was hospitalized after falling at church. From August 21, 2024, to May 3, 2025, R1 resided in a Skilled Nursing Facility (SNF). On September 27, 2024, R1 was diagnosed with an unstable wound. On March 28, 2025, R1 had a stage 2 wound on the coccyx. On May 6, 2025, following discharge from the hospital, Home Health Care assessed R1 and identified a stage 4 wound. The Department reviewed R1 records and confirmed the documentation.

The investigation revealed the following:
Allegation: Staff did not follow proper eviction protocol
It was alleged that the staff did not follow proper eviction protocol. LPA Bunker interviewed staff members S1 through S3 (S1-S3) regarding the allegation that staff did not follow proper eviction protocol. 2 out of 3 staff members stated that the facility does follow eviction protocol and is not trying to force R1 out by having the resident taken to the hospital as a form of eviction. S1-S2 stated that R1 Case Worker stated R1 needed a higher level of care. 2 out of 3 staff stated that the facility had no records indicating that R1 received a 30-day eviction notice, nor were there any records or special incident reports stating R1 was told not to return to the facility after being discharged from the Hospital.

1 out of 3 staff stated that they did not handle eviction and had no knowledge of the allegation, and confirmed that eviction protocols are handled by the Business Office Administration, not by the caregivers.

1 out of 3 staff stated that they did not handle eviction and had no knowledge of the allegation, and confirmed that eviction protocols are handled by the Business Office Administration, not by the caregivers.

2 out of 3 staff members interviewed reported that the facility follows proper eviction protocols, including communicating with a resident’s responsible party when an eviction notice is issued. 2 out of 3 staff members stated that the facility follows Title 22 regulations regarding the eviction process.

On 05/14/2025 at 11:50 a.m., LPA interviewed both witnesses 1-2 (W1-W2) together via telephone. W1-W2 stated that the facility's Executive Director (ED), along with the Wellness Director, informed them that R1 would not be allowed to return to the facility. W1-W2 stated that R1 never received an eviction notice. They were told R1 needed a higher level of care.

On 05/14/2025 and 05/28/2025, LPA Bunker reviewed the facility records and found no documentation of a 30-day eviction notice or an updated resident assessment.

Based on interviews and documentation, the Department has no records to prove that staff failed to follow proper eviction protocol.

Allegation: Staff did not communicate care needs to the resident’s representative.

On 05/14/2025 at 11:50 a.m., LPA interviewed both witnesses 1-2 (W1-W2) together via telephone. W1-W2 stated that the staff did not communicate care needs to the resident’s representative. However, W1-W2 admitted on 05/08/2025, a meeting was held with Studio Royale, R1's family, R1's attorney, and Ombudsman during which the family requested time to find a solution to place R1 in a different facility, and the facility agreed not do anything until they spoke again on 05/09/2025.

See continued LIC9099-C page 6.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099 and LIC9099-C was provided to the Executive Director Bill Boles.