complaint·August 16, 2024

Regarding the allegation “Staff do not ensure that the facility is maintained in good repair” it was alleged that for two (02) weeks the kitchen was out of order due to a gas problem. Interview with the administrator revealed that the issue pertained to the facility’s water line, not gas. Review of an incident report prior to the investigation revealed the facility discovered a maintenance issue with the water line on 06/03/24. The facility ordered maintenance from an outside vendor on 06/04/24 and notified Community Care Licensing on the same day. Interviews with the administrator, S3, and S4 revealed the kitchen had to be shut down for about two (02) weeks. LPA observed the water line in the kitchen had been dug up for maintenance. Based on record review and interviews, the facility appropriately addressed the maintenance issue in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not meet residents' dietary needs” it was alleged that during the kitchen shut down, staff served residents cold cereal, cold meals and food ordered from outside sources which was not suitable for R1. Review of the incident report noted all residents were notified of the maintenance issue and all dinners would be catered in the meantime. The facility served snacks, non-perishable foods, and cold foods through their kitchen as usual. Record review of receipts of to-go orders confirmed the facility provided dinners in sufficient quantities. Interviews with the administrator, S3, and S4 revealed they heard residents enjoyed the catered meals. Interviews with eight (08) out of eight (08) residents revealed no residents had issues with the meals served during the water outage. Record review of R1’s medical assessment revealed they were on a “No Added Salt” diet. Interview with R1 at 10:05 a.m. on 07/12/24 revealed they enjoyed the meals and had no issue with the food in general. Based on interviews and record review, the facility met the residents’ dietary needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not answer a resident's call button in a timely manner” it was alleged staff did not assist R1 in putting on their compression socks. Interview with the administrator revealed the facility told R1 that they needed to first obtain a physician’s order for the compression sock as it was deemed a medical device. Interview with staff #1 (S1) at 2:30 p.m. on 07/12/24 revealed they called R1’s physician to obtain the order. Record review revealed that by 06/17/24 the facility had helped R1 obtain the order and began to assist R1 with the compression sock as prescribed by their doctor. Interview with R1 revealed they felt the staff were good and helpful. Interviews with Staff #2 (S2) at 11:30 a.m. on 07/12/24 and S1 revealed staff are prompt and responsive to resident call button requests. Based on record review and interviews, the facility attended to R1 in a timely and appropriate manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.