complaint·September 20, 2024

approximately 12:00 p.m. on 07/18/24 revealed S1 was assisting R1 eat breakfast during the morning of 05/02/24 when R1 began choking. Interview with S1 revealed they stopped feeding R1 immediately after choking, administered first aid, and directed S2 to call 9-1-1. Record review revealed the facility submitted an incident report for the choking incident. The report noted R1 was eating soft food in an upright position. After R1 started choking, S2 called 9-1-1 and the licensee and other staff attended to R1. Record review of staff training records revealed all staff were sufficiently trained in assisting residents with feeding and residents with difficulty swallowing. Review of R1’s service plan from 03/05/24 noted they were able to feed themselves and staff were to assist with preparing and providing meals and drinks. R1’s medical assessment indicated they were diagnosed with Alzheimer’s dementia. Review of hospital records indicated that R1 experienced pneumonitis from choking on food and vomit on 05/02/24. R1 was discharged from the hospital back to the facility on 05/08/24 with hospice care. Review of R1’s hospice records indicated that R1 exhibited “dysphagia consistent with dementia” after the incident. A death report submitted by the facility and hospice records indicated that R1 passed away on 05/10/24 due to cardiopulmonary arrest along with end stage Alzheimer’s dementia. Based on record review and interviews, facility staff did not neglect R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff do not ensure facility is maintained clean” it was alleged placemats and bibs were unsanitary and never washed. During facility tour, LPA observed all interior surfaces to be sanitary. LPA observed residents eating lunch at approximately 11:30 a.m. on 07/18/24 with clean bibs and placemats. LPA also observed staff wiping placemats and the dining room table after lunch around 1:00 p.m. Interviews with the licensee, Staff #3 (S3) at 12:10 p.m. on 07/18/24 and Staff #4 (S4) at 12:35 p.m. on 07/18/24 revealed staff wash bibs in the laundry every day. Due to communication issues, LPA was only able to interview two (02) out of five (05) residents, Resident #2 (R2) at 11:00 a.m. on 07/18/24 and Resident #3 (R3) at 4:00 p.m. on 07/18/24. Both residents interviewed mentioned no issues with facility cleanliness. Based on observations and interviews, staff wash surfaces, placemats, and bibs every day ensuring the facility is clean. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff do not properly address insects in the facility” it was alleged the facility did not resolve an issue with ants. During facility tour, LPA observed no insects or trace of insects or vermin in the home. Interview with the licensee revealed a few ants were noticed in the past in the corners of the home but never on tables, in eating areas, or in resident rooms. Staff promptly used bug spray to kill the ants. S3 confirmed that they used bug spray to get rid of ants previously in the facility. Two (02) out of two (02) residents interviewed confirmed they had no issue with ants or pests in the facility. Based on observations and interviews, the facility was free of insects and vermin and properly addressed past issues with insects. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff do not meet residents' showering needs” it was alleged staff do not properly shower residents. Record review of staff training records revealed all staff had been trained on resident hygiene and bathing. Interviews with R2 and R3 revealed they receive enough assistance with showering from facility staff and an outside agency. Interviews with staff and the licensee revealed the facility revealed no hygiene issues were raised by residents, family, or visitors. Residents receive shower assistance twice a week and bed baths the other five (5) days. Based on record review and interviews, the facility meets residents’ showering needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff do not meet residents' dietary needs” it was alleged the facility did not provide sufficient amounts of food at night. Observations from facility tours today at 11:30 a.m. and at 10:30 a.m. on 07/18/24 revealed the facility had sufficient food supplies available in the refrigerator, freezer, and pantry. Interviews with residents revealed they are fed enough and have snacks available after dinner. Interview with staff and the licensee revealed residents eat food like sandwiches, fruit, nutritional shakes, and ice cream after dinner every night. No staff have heard of any issues with insufficient food at night. Based on observations and interviews, the facility meets residents’ dietary needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff force the residents to eat” it was alleged staff force feed residents too quickly. Record review of staff training records revealed all staff are trained to properly assist with resident feeding needs. Record review of resident service plans and medical assessments revealed four (04) out of five (05) residents did not require assistance eating. LPA observed staff monitoring residents during lunch on 07/18/24 and assisting Resident #4 (R4) with eating. LPA did not observe staff force feeding residents. Interviews with S3 and S4 revealed most residents can feed themselves, and staff provide assistance if requested or necessary. Interview with the licensee revealed all staff monitor and assist residents with meals. No immediate health and safety risks were observed during today’s inspection. Exit interview conducted. Copy of report provided.