complaint·March 12, 2025

Two of eight staff stated that S1 has a history of being out of compliance at work and not following directions. Interview with kitchen staff confirmed that facility has a binder for residents who have special diets that gets updated when changes are made. Based off records review, an incident report dated 10/11/2024 states that R1 was fed eggs by S1 and aspirated. Incident Report states that 911 was called and resident taken to hospital. Narrative Charting notes dated for 10/15/2024 stated that R1 was aspirating during dinner, 911 was called and paramedics arrived and suction R1. Record review of menu for October 11, 2024 for breakfast was Sausage Link, choice of cereal, pancakes and choice of juice. Menu did not match what witness reported R1 eating that day. Staff Schedule does confirm that S1 was working AM shift on October 11, 2024. Residents Physician’s Report dated 9/6/24, Preplacement Appraisal dated 9/9/24, and Needs & Service Plan dated 9/13/24 all state that R1 has a pureed diet with thickened liquids, water and Juice. Needs & Service plan states that “Residents goals for meals are to maintain adequate nutritional intake and allow enough time for resident to eat at a comfortable pace”. Preplacement Appraisal states under services needed, resident has special diet and observation of food intake. Collective Hospice Care Documents Revealed that R1 was admitted under Hospice Care on 10/16/2024. During initial visit on 10/30/2024, during facility tour LPA Tirre observed the following during visit: LPA reviewed Board in Kitchen with names of residents on special diets and observed that R1 was missing from board. LPA also attempted to view kitchen binder that has special diet orders for residents and was informed that a staff member borrowed binder and had not returned. LPA observed R1 to be sleeping in bedroom during visit and was unable to interview. Based on interviews, records reviewed and observations the preponderance of evidence has been met, deeming the allegations Facility did not ensure that modified diets prescribed by a resident’s physician as a medical necessity was provided is deemed SUBSTANTIATED. The following deficiencies are being cited per Title 22. A exit interview was conducted with Executive Director Rose Nakadaira. A copy of this report, confidential names list and appeals right was provided to facility.