complaint·February 1, 2024

(Cont. from LIC9099) where a SOC341 was filed with the Unusual Incident Report, as required. These reports are an indication that incidents are reported to the appropriate parties. Specifically, Staff 1(S1) stated that she is the one who normally reports incidents to the appropriate parties, including the ombudsman, doctor and family of residents involved, Community Care Licensing Division and Law Enforcement, if necessary, once she is informed of an incident by her staff, who she said complete an internal report using a program called Point Click Care. S1 also said she is currently training Staff 2 (S2) to assist in completing all of the required reporting for unusual incidents and that S2 has done all the reporting required for some incidents, but is still being trained. S2 was able to state the external reporting requirements, as well as her internal ones, to LPA when asked. Although Interviews with residents revealed that they did not know what the reporting requirements were for staff when an unusual incident occurs, they did indicate that staff responded appropriately to unusual incidents. It was also alleged that staff do not meet residents' dietary needs. During a tour of the facility, LPA observed lunch being served to residents in the dining room, and the meal included hot dogs, French fries, fruit and beverages. Staff interviews confirmed residents are served three meals a day, plus snacks. LPA also reviewed the menu for a week, which showed three meals are served daily, along with two snacks. The breakfast meal consist of a variety of choices, including hot or cold cereal, along with eggs, a meat item, waffles or similar item, among other choices and beverages. The choices for lunch included, but were not limited to Philly Cheesesteak, Fried Shrimp, Chili dogs and Chicken Burgers served with fruit, beverages and other side items. Weekly dinner choices included, but were not limited to Pork ribs, beef stew, spaghetti with meatballs and chicken Parmesan served with vegetables and a starch like rice, beans, potatoes and/or bread, and other side items and a beverage of choice. LPA also reviewed an A La Carte Menu, which included a choice of sandwiches, eggs, burgers, fish, fruit and other items, and staff and resident interviews confirmed this optional menu was available to order from if residents did not want the items being served from the main menu. Interviews with residents and outside sources also confirmed that residents are served three meals a day, plus snacks, along with beverages, and all residents interviewed stated that the food was either really good or good, except for R1, who stated the food was fine overall, but could be better and was served at room temperature 80% of the time, but if R1 asked for their food to be reheated they said that request was met. (Cont. on LIC9099) (Cont. from LIC9099) No other residents complained about the temperature of food served; however, S1 stated she had heard complaints about residents' food being cold, but said that problem was during a COVID Outbreak from 11/30/2023 to 12/21/2023 when residents were all being served meals in their rooms instead of using the dining room in order to limit the spread of COVID. S1 said meals were transported to rooms in "Hot Boxes", but the Hot Boxes slowly cool once they are unplugged from the wall, so residents served towards the end of a meal service, as opposed to at the beginning, were more likely to have meals served to them that had cooled. Interviews with residents and outside sources also supported the conclusion that the food variety was either good or very impressive. Interviews with residents and staff also supported the conclusion that fruits and vegetable are served daily and fresh fruits and vegetables are served as often as daily or when they are available. Based on LPA observations, interviews conducted and records obtained and reviewed, the allegation that facility staff do not meet residents' dietary needs and do not report incidents to appropriate parties is Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with Business Office Director, Amanda Togia. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to Director Togia, and their signature on this report confirms receipt of the report. .