Complaint Investigation Report

On 7/25/2021, it was noted that R1 experienced a change of condition. Interviews with R1’s family member and the Administrator revealed that R1 appeared lethargic, was not eating and was refusing medication. A review of hospice chart notes, on 12/7/22 starting at 8:15 a.m., revealed that on 07/25/2021, the hospice nurse, R1’s family member and the Administrator agreed to revoke hospice services and send R1 to the hospital. Upon admittance to the hospital, it was discovered that R1 was diagnosed with pneumonia. From the hospital, R1 was then transferred to a skilled nursing facility. The family indicated that R1’s pressure injuries worsened at the skilled nursing facility, and R1 sent back to the hospital for treatment of the injuries. R1 eventually was re-admitted to Bella Nova II on 09/04/2021. R1’s family member added that the hospital gave them a choice of going back to the skilled nursing facility or back to the facility. R1’s family member decided to move R1 back into Bella Nova Villa II on 09/04/2021. When R1 was re-admitted to Bella Nova II, R1 was also re-admitted to hospice services. Further review of hospice documentation revealed that on 09/04/2021, R1 was re-admitted to hospice services with a diagnosis of Alzheimer’s Disease, pressure ulcer of other site unspecified stage, and eight (8) other medical conditions. R1 passed away on 09/13/21.

Interview with hospice worker on 01/09/2023, starting at approximately 1:18 p.m., could not provide substantial evidence that R1 needed a higher level of care, but stated that their concern was one (1) care staff was present while at the facility during a visit. However, per interviews conducted with staff, there was insufficient evidence gathered to support the claim that R1 did not receive adequate care. Although R1 was sent to the hospital and was treated for pneumonia, interviews and documentation indicated that there was no change of condition in which R1 required a higher level of care while at Bella Nova II. Based on evidence gathered, the allegation resident requires a higher level of care is deemed unsubstantiated at this time.

Also being alleged is insufficient staffing to meet resident needs. On 09/17/2021, LPA Kelly Dulek conducted a facility tour starting at approximately 10:30 a.m. and observed two (2) staff present. On 11/17/2022, LPA Ascencio conducted a facility tour starting at 12:15 p.m. and observed two (2) staff members present at the facility. LPA Ascencio also observed six (6) resident that appeared to be clean, and well-taken care for. LPA observed residents asking to use the restroom and staff members attending to the needs of the residents. LPA also observed resident bedrooms that were set up with beds with clean linen. Appliances in the kitchen were clean. All rooms were free of odors and appeared clean. At the time of visit, LPA also observed meals being prepared and served to residents in a timely manner.