complaint·September 12, 2022

Allegation- Residents personal belongings were not safeguarded while in care. The department conducted Interviews and record review to investigate this allegation. During record review, department observed documentation regarding the allegation concerning R1’s missing eyeglasses. Facility Executive Director (ED) was notified by R1’s family on 02/02/2022 that R1’s eyeglasses were missing. ED followed up on R1’s missing item and issued a one-time refund of $330.00 on 02/03/22 to the family. This was the only missing item that was mentioned for R1. Although the facility provided R1’s family a refund for R1’s missing glasses, the facility did not safeguard R1s personal belongings while in care at the facility therefore the allegation is SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview with Marianne. Appeals rights provided. Copy of the report left at the facility. Allegation- Residents ADLS were not met by facility staff. The department conducted Interviews, facility inspection and record review to investigate this allegation. Chart notes indicate that the resident's needs - bathing, grooming, oral care, dressing, eating, diet, toileting, escorting, transfers appear to be addressed and notated / documented by on facility staff. During facility observation on 04/13/22, department has observed that residents appeared to be well groomed and in good care. UNFOUNDED Allegation- Residents are not getting a sufficient amount of food while in care. The department conducted Interviews, facility inspection and record review to investigate this allegation. Records review of menus that are posted in the common area of the facility list nutritious meals that are offered to the residents that meets regulations requirements. During staff interviews, staff stated that residents do complain about the quality of food sometimes. During residents’ interviews, residents stated the food that is served is good quality. Record review also indicate that facility staff follow any resident’s dietary needs per physician’s orders. During facility observation for lunch on 04/13/22, department observed that residents were served a nutritious meal with sufficient portion sizes. During record review for R1, there is no evidence to suggest that R1 was losing weight due to food provided by the facility. Facility was checking R1s weight on monthly basis and department did not observe any weight loss during record review for R1. UNFOUNDED Allegation- Facility staff retaliated against resident's responsible party. The department conducted Interviews and record review to investigate this allegation. Based on facility record review and interviews, it has been concluded that facility did not retaliate against R1’s responsible party in any manner. R1 was admitted to the facility on 01/26/2018 and expired on 02/27/22. It was determined through the investigation that the facility made accommodations such as monthly care meetings, informing R1s doctor, family for any health updates/changes and addressing any other concerns in timely manner. R1s family was invited to attend several care plan meetings and facility provided all that information to department while doing record review for R1. UNFOUNDED **Report continued on LIC9099-C** Allegation- Resident developed an infection while in care. The department conducted Interviews and Record review to investigate this allegation. Department has reviewed the records for this complaint investigation for R1 regarding developing infection while at the facility. Upon records review, department observed care notes from the facility which indicated that on 02/09/22, Home Health (HH) saw R1 at the facility for a right toe infection and marked the wound as stage 2. HH provided R1 with appropriate treatment including antibiotic therapy as indicated in 02/08/22 in facility care notes. Upon records review, department observed care notes for R1 from facility from 01/01/22 through 02/27/22, which indicated facility staff and HH were aware about R1's buttock's wounds. Per record review, HH documented the treatment for all of R1’s wounds, including cleansing with wound cleanser and applying calmoseptine ointment. All of R1’s wounds were documented as stage 2 wounds. Per facility records, on 02/25/22, HH advised facility and family that it would be beneficial for R1 to be admitted to a skilled facility until R1’s wounds healed however R1s family declined and expressed that family would like R1 to stay at the facility. Per physician orders and family's consent, R1 was admitted on Hospice care on 02/26/22 and R1 expired on 02/27/22. Per facility records, R1’s physician, family and facility staff were aware about R1's change in health condition and care plan, therefore it has determined that resident did not developed infection due to facility’s lack of care. UNFOUNDED Allegation- Insufficient staff to meet residents needs. The department conducted Interviews, facility inspection and record review to investigate this allegation. Chart notes indicate that the resident's needs - bathing, grooming, oral care, dressing, eating, diet, toileting, escorting, transfers appear to be addressed and notated / documented by on facility staff. During facility observation on 04/13/22, department has observed that residents appeared to be well groomed and in good care. UNFOUNDED Based on records reviewed, Interviews and observation , the above all allegations are found to be UNFOUNDED . A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Marianne and a copy of this report was provided to the facility. No deficiencies cited. The signature of Marianne on these forms acknowledges receipt of these documents.