Complaint·June 30, 2022

After the funeral, R1 was observed by staff and outside sources to be sleeping more and eating and drinking less. R1’s sibling also passed away in June 2021. Staff stated that in response to this behavior change, they gave R1 milk shakes and R1's choice of fast food and facility food. Record review revealed that starting in April 2021, facility staff were working with R1’s physician and home health services regarding R1’s decreased food intake and scheduled multiple medical appointments in May 2021. Interviews with staff also revealed that facility staff offered R1 water whenever staff interacted with R1 and R1 was able to drink unassisted. Onsite visits and interviews revealed R1 did not have any issues with the care R1 received at the facility and was offered drinks throughout the day and with meals. During onsite visits, R1 was observed with drinks and snacks. Review of medical documents from R1's hospitalization on 6/28/21 revealed that R1's weight was recorded on 6/28/2021 at 9:04am at 120 pounds and 5.9 ounces. On the same day at 9:31pm, R1's weight was recorded at 70 pounds and 12.3 ounces. Interviews with R1's primary physician stated that it appeared that R1's weight was entered in error due to the vast discrepancy in weight history. Interviews with facility staff and Licensee revealed that between late 2020 and April 2021, R1 lost approximately 40 pounds while living at another community care facility. The Department’s investigation consisted of interviews with staff, residents, and outside sources, review of records, and a tour of the facility. It was alleged that facility staff did not treat the resident’s scabies. Review of fax documents between the facility and R1’s primary physician revealed that the facility was in communication with R1’s primary physician regarding R1’s skin conditions between 3/3/2020 and 7/2/2021. Interviews with outside sources revealed that R1 had a history of heat rashes. The facility contacted R1’s primary physician on 5/18/2020, 5/19/2020, and 5/23/2020 regarding R1’s shingles diagnosis and the care plans for treatment. On 5/20/2021, R1 attended a medical appointment where R1 was diagnosed with scabies and prescribed a topical cream and topical ointment. On the same day as the medical appointment, the facility contacted R1’s primary physician to notify them of R1’s scabies diagnosis. Facility staff applied a topical medication to treat the scabies, disinfected R1’s belongings, and increased the frequency of R1’s showers. On 6/28/2021, R1 was diagnosed with scabies at the hospital. The facility contacted R1’s primary physician, moved R1 to a new room, and cleaned and sanitized R1’s belongings and furniture. On or about 7/2/2021, R1 was not showing any improvement with the skin condition and the facility contacted R1’s physician to request updated care plans. Continued on LIC9099-C Page... Investigative interviews revealed that R1 was treated for scabies and the facility’s physician had determined that R1’s scabies was not active and that scarring from the scabies could last for months. Interviews with outside sources and R1’s physician revealed that R1 was undergoing treatment for the scabies. R1’s physician also did not have any concerns about the care being provided at the facility. The Department has investigated the above-mentioned allegations and based on observation, interviews, and record review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Administrator Maria Flores, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.