complaint·December 6, 2022

Facility staff were trained to call the outside agency if the wound smelled, looked infected, had any changes, or if the bandage slipped or fell off. Facility medication technicians and nurses had received training to replace the bandage on the wound if needed, but were still instructed to call the outside agency to notify them of the changes. Interviews with the outside agencies revealed that there are no concerns about facility staff reaching out to them regarding residents’ wound care. Interviews with Resident 1’s (R1) home health nurse stated that R1 was non-compliant with wound care and would not allow staff or outside agency staff to observe or care for the wound. R1’s nurse arranged a care conference with the facility’s HWD to discuss R1’s wound. Interviews with HWD stated that R1 would be non-compliant with home health nurses depending on how they approached R1 and would agree to care from some nurses and deny care from others. Review of home health care documents revealed that R1 occasionally denied services but was able to receive wound care services. HWD stated that R1’s wound had healed as of October 21, 2022 and R1 is no longer receiving wound care services. It was alleged that staff served expired food to residents and did not follow food sanitation practices. Interviews with the staff revealed that staff conduct inventory on the facility’s food supply and order food supplies once a week. Staff are directed to fill out a food label when preparing food which includes the name of the food, the date prepared, the expiration date of the food, the food’s shelf-life time period, the preparer’s initials, and the manager’s initials. During the initial visit on August 15, 2022, LPA Ruiz observed food in the facility’s walk-in refrigerator and freezer that had the date prepared but did not have the expiration date or a shelf-life time period. LPA Ruiz did not observe any food that was spoiled or rotten during the initial visit. Interviews with the Dining Services Director (DSD) revealed that there is a specific staff member that is having an ongoing problem with not putting the expiration date on food. Interviews with dining staff revealed that any food that is identified as spoiled or expired is thrown out. Interviews with residents revealed that residents like the food served at the facility and have not observed any spoiled or expired meals. Interviews with staff revealed that dining staff are responsible for cooking and preparing meals in the facility kitchen, placing the food into warming boxes that are used to transport food to the facility’s two dining rooms for assisted living and the two memory care areas. Continued on LIC9099-C page. Dining staff transfer the food into steam trays in kitchenettes located in each dining room and plate and serve food to residents. In memory care, dining staff transport the warming boxes to the memory care kitchenettes where memory care staff place the food into steam trays and plate and serve residents. Interviews with the DSD revealed that dining staff use gloves when preparing food. The Department has investigated the above-mentioned allegations and based on interviews, observations, and review of records, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Executive Directors Mario Preston and Chris Burk , to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.