complaint·February 2, 2023

…continued from LIC9099 Allegations: Residents have developed pressure injuries while in care Residents are not being provided a sufficient quantity of food Residents are not being provided a sufficient quality of food. Residents are not being rotated while in care Facility has pests Investigation Findings: UNSUBSTANTIATED LPA interviewed four (4) Staff (S1, S2, S5, S7) of seven (7) and confirmed they did not observe any bruising or pressure injuries on Residents (R1, R2, R3, R4) while in care at the facility. R3’s Physician’s Report dated 05/14/21 documents a history of skin condition – breakdown. Per S1 and records, there weren't any physician's orders for R3's dry skin condition from date of admission 03/21/22 to discharge date of 10/23/22. Care staff would apply Aveeno lotion to obvious signs of dry skin as prevention and to aide R3's dry skin. On 03/29/22, LPA observed two (2) Residents in the dining room eating dinner; S8 was preparing the food for the residents. One (1) Resident was watching television. S2 stated that S8 was a good cook. S2 not only shopped and purchased food/goods for the facilities, but also for the Staff to take home in order to cut down on the number of trips to the store and the potential spread of COVID-19. On 01/04/23, S1 provided three (3) monthly sample menu’s that appeared to be balanced meals for breakfast, lunch, two (2) snacks, dinner and desert consisting of a variety of daily nutrients. LPA observed what appeared to be a soup/stew being served, a dinner roll, juice and coffee. Interviews with Witnesses (W1, W4) and record reviews revealed that R1 passed away 10/28/22, was diagnosed with Dementia, and that the facility aided R1 with research treatment and overseeing the donation of R1’s remains to science. W4 stated R1 is a fall risk, has had falls multiple times but is very independent. W4 feels like R4 is safe and both S1 and S2 have been a great help. W4 has been satisfied with the level of care since R4 moved into the facility in 2019. R5’s Physician’s Report dated 04/01/21 revealed R5 as having sundowning syndrome; R5 likes to sleep during the day and was noted having redness on his/her back; there were no additional orders. S1 stated that R5 likes to sleep all of the time, doesn't like to shower and shave often. R5 and R6 do not have any mobile impairments at this time, R1 was not a fall risk and health declined fairly quickly. continued on LIC9099C... ...continued from 9099C Pest Control inspections, records and receipts revealed that the facility has had a proactive treatment plan in place with Terminix since 10/03/17. The quarterly report for 01/11/22 targeted ants, and on 04/12/22 there were no further recommendations or concerns. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited, exit Interview conducted and a copy of this report provided to Administrator, Nalini Bhutani.