complaint·October 20, 2023

Allegation: Facility meals do not meet the needs of the resident(s). It is alleged that resident (R1's) physician ordered restricted diet is not meeting the resident's nutritional needs because residents are served very small meal portions, the food is of low quality with no vegetables, and all the food appears processed. According to information obtained, resident (R1) has physician orders for a diabetic diet. A total of eight (8) residents were interviewed, of which one (1) resident stated the food served is not meeting their needs. The facility serves open breakfast meal. Lunch and dinner are set menus. There is an alternate menu as well. Snacks are served and health shakes are served four (4) times a day in addition to their meals for residents that are low weight. A total of four (4) staff were interviewed, it was acknowledged that resident (R1's) Physician's Report stated the resident requires a Diabetic diet, but the resident was not placed on the restricted diabetic diet due to an oversight. Per record review, the findings indicate that resident (R1) has not added to the Specialized Diet list during the time the resident resided at the facility. Allegation: Resident's bathroom is in disrepair. It is alleged that the screws of the stainless steel grab bar in resident (R1's) the bathroom tub area were loose. The resident tried to stabilize their self upon exiting the shower chair and the resident fell back and almost hit their head, but no injuries were sustained. According to reporting party, Administrator was informed of the hazard, but it was not fixed for at least 3 days. Staff interviews revealed that when resident (R1) moved in the room was checked. It is unknown if the grab bar became loose after resident use, or whether it was a staff oversight when they completed the Apartment Safety and Cleanliness inspection. According to Administrator, preventative maintenance on resident rooms is done on a quarterly basis. LPA inspected eight (8) rooms, none had loose bathroom grab bars. A total of eight (8) residents were interviewed, only resident (R1) reported loose grab bars. Based on observation and interviews conducted, the findings indicate that resident (R1's) bathroom had loose grab bars likely due to staff oversight during the move-in activity, but staff reported it was not intentional. The grab bar was repaired on 4/25/2023. Based on record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D. An exit interview was conducted and a copy of this report and appeal rights was provided to Administrator Denise Sutton. Allegation: Facility staff did not dispense resident's medications as prescribed. It is alleged that on 4/18/2023, resident (R1's) PRN "Hydrocodone-Acetamin 5-325 mg medication was not administered per physician order i.e. every six (6) hours as needed because the medication was brought to the resident at 3:00 AM instead of 2:00 AM, which resulted in "suffering". According to information provided, the resident was being given the PRN medication, but on at least two (2) other occasions it was late as well. Resident (R1) stated that the medication was to be administered routinely every 6 hours. A total of eight (8) residents were interviewed, of which one (1) stated that their medications are not dispensed as prescribed. Per staff interviews, the PRN medication was to be administered every 6 hours. The medication order was not changed by Dr. Chen until 4/20/2023. The new physician's order was changed to every four (4) hours routinely, "hold if pt is asleep". Per record review of Narcotic Drug Record and Medication Administration Records, it was noted that the PRN "Hydrocodone-Acetamin 5-325 mg medications was not always administered every 6 hours. However, based on record review of physician's orders the medication was changed to every 4 hours routinely until 4/20/2023. Therefore, facility staff followed physician's orders. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Denise Sutton. A copy of this report was provided.