complaint·October 3, 2024

Interviews conducted with staff revealed, R2 had trip and fallen in the dining room on 4/18/24. Staff assisted R2, who was send out to the hospital via emergency services. Interview conducted with R2’s family member who was present during the fall revealed R2 made a sudden turn and fell, sustaining a hip fracture. Per family member facility staff assisted right away, paramedics were called, and R2 was send out to the hospital. While at the hospital R2 was not able to obtain surgery for the hip fracture due to other health conditions and passed away on 4/25/24 at the hospital. Documents reviewed revealed, Incident report dated 4/22/24, notes R2 suffered a mechanical fall in the dining room on 4/18/24 at 5:30pm. Paramedics were called and was transferred to the hospital. Service Plan dated 12/28/23 notes R2 is independent, self-care, with occasionally needing verbal cues. Per physician’s report dated 5/1/23 R2 did not have any motor impairments. Regarding R3, interview conducted with administrator revealed R3 had been at the facility for about 4 weeks and did not show any changes in condition or other signs of distress. On 7/10/24, staff conducting checks found R3 in the room unresponsive. Paramedics were called and R3 was declared death. Documents reviewed revealed the following: Per incident report dated 7/9/24, R3 was found in the room on 7/3/24 at approximately 12pm by a caregiver not responding to verbal commands. R3 was assessed by medication technician, who observed R3 was weak, vomiting, and unresponsive to verbal commands. Emergency services were called and R3 was transfer to the hospital. R3 was hospitalize, received treatment, and return to the facility on 7/8/24. R3’s physician’s report dated: 5/16/24 notes R3 had a history of congestive heart failure. Death report dated 7/10/24 notes, on 7/9/24 R3 was found in their room by a medication technician during check rounds. Paramedics were contacted, arrived at the facility, after evaluating R3 declared time of death at 7:42pm. Death report notes cause of death as cardiopulmonary arrest. Although both deaths were sudden there were no changes in condition, prevention, or lack of staff care that could have prevented the deaths of R2 and R3. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are not providing adequate food service to resident. It is alleged R1 was on a vegan food program. However, R1 was forced to buy own vegan food for the chef to cook and was not provided vegan meals by the facility. Interviews conducted with residents revealed facility facilitates meals to residents’ dietary needs or preferences and are satisfied with the meals provided. (CONTINUED ON LIC 9099C) Interviews with staff revealed facility staff are able to identify residents with special diets, allergies, or meal preferences which they follow to provide the meals to the residents in care. Kitchen staff are aware of R1’s vegan meals preference and arrange for R1 to received vegan meals daily. Interview with Culinary Director revealed R1 had shown a desired for certain products that the facility was not able to accommodate as food produce vendor did not carry does specific items. However, culinary director had accommodated other brands or substitutes to provide the meals for R1. Document review revealed R1’s facility’s nutritional profile dated 3/22/24 notes vegetarian meals. Physician’s report dated 3/21/24 notes R1 has a vegetarian diet with regular textures. Although R1 may have had preferences in vegan items or produce, interviews conducted revealed the facility provided vegan meals for R1 with accommodations of produce they were able to obtain with food company they vendor with. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are not meeting residents needs. It is alleged facility staff are not assisting residents with dementia to seat at the dining room table and wheels of residents in wheelchairs are getting stuck in the elevators’ gaps. Interviews conducted with residents revealed residents feel satisfied with the care and assistance the staff are providing to them. Residents that need assistance with wheelchairs stated to be able to get into the elevator without difficulties and wheels have not gotten stuck in the gaps of the elevator. Interviews with staff revealed, at mealtimes staff remind residents to their usual chair when they seem confused and are not left unattended. Also, staff assisting residents in wheelchairs have not have incidents in which wheels get stuck in between the gaps or the elevators’ doorway. During facility’s tour on 8/27/24 LPA observed facility’s elevators in working condition and no large gaps were observed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.