complaint·January 6, 2022

The functional capability assessment was conducted via tele-visit, by the administrator in training, who was a licensed medical professional. On 02/10/2020, Upon admission to the facility R1 was identified by the facility staff as a fall risk resident requiring close supervision. Although facility staff had knowledge that R1 must be under the staff supervision all the time, between 02/17/2020 and 03/05/2020 R1 had two (02) fall incidents with injuries and both times staff stepped away and was not present at the time of fall. Between 03/17/2020 and 05/23/2020 IB investigator reviewed various facility records as well as medical records obtained from the hospital. The information revealed from the documents verified and the information revealed from the interviews. Therefore, based on the interviews and record review, the allegation is SUBSTANTIATED at this time. responsible party made a decision to move R1 from the facility. On 02/12/2020 at 2:30pm, LPA Margaryan requested various facility records for review. On 03/12/2020 at 3:30pm LPA Margaryan spoke with R1’s responsible party that was present at the facility during licensing visit and she indicated that she did receive an e-mail from the facility. However, the attached documents were incomplete. R1’s responsible party was unable to provide copies of the incomplete documents received from the facility staff via-e-mail. A review of the facility records completed on 03/25/2020 at 4:00pm verified that R1’s care plan and other relevant documents were completed upon admission and were e-mailed to R1’s responsible party for review and signature. Based on the interviews and record review, there is no sufficient information to support the allegations. Therefore, the allegations are UNSUBSTANTIATED at this time. Staff denied resident food. It was reported that R1 was hungry and staff refused to give R1 food. On 03/12/2020 LPA Margaryan was present at the facility between 8:30am and 5:30pm. During licensing visit LPA Margaryan inspected the kitchen and observed the facility food supply. On 03/12/2020 around 12:00pm LPA observed R1 eating lunch and facility staff providing feeding assistance. The staff prepared a soft food and soup for R1. On 03/12/2020 at 2:00pm LPA Margaryan spoke with the facility staff preparing the food for the residents. Interviews revealed that every morning in addition to other food items served to R1, staff also serves R1 two (02) boiled eggs. On 03/12/2020 around 10am, while LPA was present at the facility, R1’s family member came to visit R1, a few minutes later, R1’s family member came to the kitchen and accused staff of not feeding R1. The staff explained that R1 already had breakfast and as usual had two (02) boiled eggs. The family member continued to insist to give two (02) more eggs to R1 and the staff offered to give R1 other foods but no more eggs. On 03/12/2020 around 2:30pm, LPA Margaryan spoke with R1 and R1 was unable to remember what they had for breakfast and lunch. Based on inspection, observation and interviews, there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Staff are not following Dr. orders for a pureed diet: It was reported that R1 is suppose to receive a pureed diet and the staff feds the resident soup. During investigation on 03/12/2020 LPA Margaryan inspected the kitchen and observed the facility food supply. The facility had appropriate quantity and variety of food. On 03/12/2020 around 12:00pm LPA observed R1 eating lunch and observed facility staff assisting R1. R1 was served a soft food and soup. On 03/12/2020 between 2:00pm and 2:45pm, LPA Margaryan spoke with the administrative personnel and the facility staff preparing the food for the residents. Interviews revealed that as per physician report submitted to the facility, R1 was not on a prescribed medical diet. However, as per R1’s responsible parties request, the staff was making soft food for R1. On 03/25/2020 at 4:00pm LPA Margaryan reviewed R1’s physician report signed on 09/10/2019 and the document does not indicate that R1 was on a special diet. Based on the interviews, observation and record review, there is no sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.