Interviews further revealed that one resident was typically soiled in the mornings due to frequent urination, but was changed by staff at regular intervals. No staff observed another staff yelling at residents or treating them without dignity.

Outside source interviews corroborated staff statements regarding residents on hospice care at the facility. Outside source interviews did not corroborate the allegations, as outside sources had not observed staff treating residents without dignity or neglecting their care. Outside sources stated that staff communicated resident needs and provided great care.

Residents were not able to be verified as accurate historians for interview due to cognitive impairments.

Review of relevant records revealed that certain residents had diagnosed behavioral disturbances, skin discoloration, diagnosed skin issues and/or rashes, edema, unsteadiness, and pre-existing skin tears and bruises. Resident care plans showed consistent expectations of staff to assist residents with incontinence, activities of daily living, and transfers. Body check logs showed that staff documented skin issues, rashes, redness, and skin conditions. No record evidence was found to corroborate the allegations.

The evidence found does not support the allegations and shows that resident co-morbidities, behavioral and medical conditions contributed to the observed pressure injuries, bruises, and scratches. Evidence showed that some injuries/bruises existed prior to the resident moving into the facility. Due to lack of specifics regarding which allegations pertained to specific residents, correlation of abuse was not able to determined, if any. Resident records were consistent with staff statements regarding resident care. No evidence was found to show that staff did not provide the care required for each resident in their care plans, including incontinence care. Records also showed that five of six residents were being followed by either Hospice or Home Health. Evidence was not found to show that staff did not communicate care needs for any resident. Staff and outside source interviews did not corroborate the claim that staff yelled at residents.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Licensee Rina Chang, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.