Complaint·May 6, 2021

Resident (R1) central to complaint had been moved to a separate facility on 8/6/2020, where he/she had since passed away on 12/26/2020. Licensing Program Analysts (LPAs) Ryker Heberle and Marybeth Donovan were unable to interview R1 before his/her passing; however R1 was interviewed during previous complaint investigation. LPAs consulted on R1's previous interviews dated 7/17/2020 and 7/29/2020 from prior complaint to obtain/gather pertinent information. During 7/17/20 interview R1 stated that he/she was served 3 hot meals a day while at the facility. During 7/29/2020 interview, R1 stated that he/she does not eat very much anymore. LPAs reviewed resident's file from the time he/she had spent at the facility. Resident progress notes, physician notes, internal incident reports, and physician's orders indicate that the resident fell on 5/14. The fall did not lead to serious injury and was reported to resident's PCP and family, resident was discharged without update to care plan and was sent home from the ER that same day. R1's 602 (dated 7/2019) does not indicate the need for fall prevention protocols nor assistance with motor functions or transferrals. Progress notes indicate multiple instances of R1 denying food. Physician's Order from 05/08/2020 indicates a request for the facility to measure resident's weight once per month. Resident records contained a weight tracking sheet that the facility had updated monthly. Upon weight loss, facility switched R1 to soft foods diet on 5/9/20 to address his/her trouble swallowing. Progress notes indicate that facility staff encouraged R1 to eat meals and drink water. Meal service delivery reports indicate that R1 was brought food 3 times a day prepared to the standards of doctor's order from 5/19/2020. This Department has investigated the above allegations. Based on interviews and records review, the Department has determined that the allegations are UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Report reviewed with Tami Ojwang, General Manager, and a copy of this report provided electronically for signature.