complaint·October 9, 2024

Continued from LIC 9099 On 02/27/2024, LPAs V. Conway and M. Arroyo conducted an initial 10-day visit. During today’s visit, the LPAs conducted a physical plant tour to ensure there are no immediate health and safety concerns at 10:58 a.m. At 11:10 a.m., the LPAs toured the Memory Care unit and observed random resident bedrooms. Between 10:20 a.m. and 2:15 p.m., the LPAs conducted interviews with the ED, three (3) staff, five (5) residents including R1, and two (2) private caregivers (PCG). At 11:48 a.m., the LPAs also conducted a resident file review and obtained copies of pertinent documents relevant to the investigation. Additionally, on 08/28/2024, LPA Conway conducted additional interviews with random staff, and hospice agency staff that were providing services to R1. Interviews conducted revealed that facility staff consistently deliver pureed food to R1. However, R1 has been refusing the meals. Interviews with hospice agency staff reflected that a new order for pureed food and nutritional drinks were sent over for R1 on 08/25/2023. On 08/26/2023, Hospice agency staff contacted the facility staff to ensure that the new dietary orders were been followed. Facility staff confirmed new orders and informed hospice staff that R1 also refused to eat the pureed food. On 08/29/2023, hospice nurse met with R1 who expressed that they did not want to eat the provided food. Hospice physician ordered nutritional drinks for R1 to ensure they receive an adequate source of nutrients during this time. This measure was intended to support R1’s nutritional needs as pat of their care plan. Moreover, information gathered during the course of the investigation reflected that for those residents that are unable to go to the dining room, staff deliver their meals directly to the residents’ rooms three (3) times a day. Additionally, all employees have access to a board in the kitchen displaying a list of residents’ names, along with their special diets, food allergies and unit numbers. ED stated that as soon the facility receives a new physicians order for a special diet, management immediately communicate those changes to the chef, who promptly updates the meals served to the resident. Based on information gathered, the Department does not have sufficient evidence to determine that the R1 was not adequately fed. Therefore, the above allegation “staff did not ensure resident was adequately fed" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted. A copy of the report was provided.