complaint·September 16, 2021

It was additionally noted that R3 was on a blood thinning medication (Plavix) which is known to cause its users to be easily susceptible to bruising. Side effects regarding this medication and R3's bruises were discussed with R3's doctor, who confirmed that the medication causes patient to easily bruise and even experience sub-dermal bleeding. Based on record review and interviews conducted, the allegation of "Residents have unexplained bruising" is UNSUBSTANTIATED. Regarding allegation "Food service is inadequate": LPA Colvin reviewed the facility's Dietary Quarterly Quality Assurance Reports for the last 12 months, as well as the sample menu provided by the Administrator to LPA Colvin. LPA Colvin observed that in the Quarterly Reports (which are conducted by Registered Dietician from outside of the facility) the facility has maintained an "A" grade, with 100% rating for Meal Service and Nutritional Assessment in the last 4 reports. LPA Colvin additionally observed that the facility was docked a few points from their score in Sanitation for minor errors, which do not correlate with the concern in the complaint, which is specific to the portions of the food being served being inadequate. Based on record review, the allegation of "Food service is inadequate" is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of this report was provided to Resident Services Director Barbara Bogoje . LPA Colvin reviewed R2's history of care at the facility and observed that R2 had a history of developing pressure injuries, and with the assistance of wound care from Hospice, R2's pressure injuries tended to heal. R2's Hospice records show that the nurses from Hospice that would treat R2's pressure injury would consistently communicate with facility staff, provide training and instruction, and order additional supplies (such as low air loss mattress) for R2 in order to attempt to treat R2's worsening pressure injury. Therefore, due to interviews and record review, the allegation of "Resident developed a bed sore while in care of facility" is UNFOUNDED. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted, and a copy of this report was provided to Resident Services Director Barbara Bogoje. In LPA Colvin's interviews, R1's weight loss was attributed to R1 not eating or drinking for long periods of time, yet during LPA Colvin's review of the facility records, LPA Colvin observed that this was not documented in any documentation provided to LPA Colvin, nor in any documented correspondence to R1's physician. In LPA Colvin's investigation of the allegation, LPA Colvin confirmed that R1 was hospitalized for dehydration in addition to other medical concerns, all of which were unobserved by facility staff, who failed to adequately document the R1's changing condition or seek timely medical attention for the resident. Due to LPA Colvin's review of the facility's file, the resident's medical records, and interviews, the allegation of "Resident was hospitalized for dehydration" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to investigation that was conducted by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099 D. An exit interview was conducted with Resident Services Director Barbara Bogoje where this report and appeal rights were discussed. A copy of this report, LIC 9099D, and appeal rights were provided to Resident Services Director Barbara Bogoje during the exit interview.