Complaint Investigation Report

Based on records reviewed, R1 moved into facility on December 6, 2023. Records showed, R1 was receiving wound care from Home Health Provider for elbow and sacral wound since October 2023. According to records, sacral wound being treated was as a Stage 2 pressure ulcer. Interview with Home Health provider confirmed R1 was receiving twice weekly visits from home health. Records reviewed also revealed that R1 was transferred to Hospice care as of December 26, 2023, due to requiring a higher level of care. Interview with caregivers revealed that R1 was rotated every two hours and changed as necessary. Interview with Hospice Agency revealed there were no concerns with the level of care provided to residents at the facility. Interview with Hospice also confirmed Hospice agency is now providing care to pressure injury. Interview with outside source revealed that there was no suspected neglect to R1.

It was also alleged that facility neglect resulted in R1 being malnourished. Records reviewed revealed R1 could feed self. Interviews with staff revealed R1 only eats about half of their servings. Records reviewed revealed R1’s has declined cognitively since September of 2023 and has increased lethargy. Records also revealed R1’s appetite ranges from Good to Fair, week by week. Lastly, records reviewed revealed R1’s Body Mass Index is 19.1. According to the Center’s for Disease Control and Prevention (CDC) 19.1 is considered healthy weight.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Owner Matthew DelBruegge to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.