Allegation 2 - Resident sustained injuries while in care The investigation did not provide sufficient evidence to substantiate neglect/lack of supervision against facility. Though resident had minor bruising to residents’ thighs, there was no indication the bruises were a result of abuse, neglect and/or lack of supervision. The bruising appeared to be a result of routine care and/or accidental means as there is no evidence to suggest otherwise. Resident took a daily blood thinner in the form of aspirin and was visited by registered nurses, social workers, spiritual counselors, licensed vocational nurses, and no concerns of neglect and/or lack of supervision were previously reported.

Allegation 3 - Resident developed sepsis while in care. The investigation did not provide sufficient evidence to substantiate neglect/lack of supervision against facility. Residents’ hospice records indicated that resident was a fall risk when resident was put on Hospice on 06/10/20. The hospital medical records, resident was diagnosed with clostridium perferinges bacteremia, but as stated by a W#6, "It is unclear to them or the infectious disease doctor how resident acquired clostridium perferinges sepsis with bacteria growing in resident’s blood. They are not sure how resident got the bacteria in resident’s blood or if the facility is responsible."

Allegation 4 - Staff did not meet resident's hygiene needs. Interviews conducted with S#1 – S#12, communicated that all residents are showered, clothes, and feed. Depending on the residents they all have a bath schedule for different times and dates. The resident was diagnosed with progressive Alzheimer’s Dementia, staff would help resident with all their ADL’s. They all deny that the resident’s hygiene needs are not met. They take care of every resident’s needs all the time. Interviews conducted with R#1 – R#12, communicated that their needs are always met. The staff showers, feeds, and changes their adult diaper and clothes. The staff is very helpful, they always help them with all their needs. LPA reviewed the shower/bathe schedule for residents, and all have times and dates assigned for that specific task. LPA observed some of the residents while touring the facility, the resident’s appearance was nice and clean. Their hygiene was good, and their clothes were clean. The interviews and records reviewed do not concur with the above allegation.

Allegation 5 - Staff did not provide an adequate amount of food to resident. Interviews conducted with S#1 – S#12, communicated that all residents are fed 3x times a day with good size portions of food. They receive protein, vegetables, and fruits. They get whatever drink they want unless they have special diets or restricted drinks and/or foods they are not allowed to eat and/or drink. If residents do not come to the dining room their food is taken to them. The resident was on a special diet, resident could only eat soft foods, resident would hardly eat, resident did not have much of an appetite, resident’s health was declining, resident was on hospice. They all deny that the resident does not get an adequate amount of food. Interviews conducted with R#1 – R#12, communicated that the food portions are good. Sometimes they feel they give too much. If they request more food the staff always brings them 2^nd. The food is good, they have no complaints. LPA reviewed the menu for 1 month. The menu has healthy and a variety of different meals on the menu for residents to choose from. LPA observed the food being served for lunch. The food potions were enough, and the meat and vegetables were fully cooked. R#1’s hospice records indicate that R#1 only ate 30% to 40% of her meals, due to her health. The interviews, records, and observations do not concur with the above allegation.

Allegation 7 - Resident was left in a soiled diaper. Interviews conducted with S#1 – S#12, communicated that all residents are always have their adult diapers changed. The care givers checked them every two hours for soiled adult diapers. The residents have not complained of being left for hours in their soiled diapers. Interviews conducted with R#1 – R#12, communicated that some don’t use adult diapers they go to the restroom on their own and others have staff help them all the time. LPA reviewed the hospice notes, the resident was being checked regularly for soiled diapers. The interviews, records, and observations do not concur with the above allegation.

Allegation 8 - Resident served undercooked food. Interviews conducted with S#1 – S#12, communicated that all residents are fed 3x times a day with fully cooked and good size portions of food. They receive protein, vegetables, and fruits. The kitchen has never served raw or under cooked meat. Some of them eat at the facility and they have never been served uncooked meat. Resident was on a special diet. Resident could only eat soft foods. Resident would hardly eat, did not have much of an appetite, and health was declining. Resident was on hospice. They all deny that the residents are served under cooked meals. Interviews conducted with R#1 – R#12, communicated that the food portions are good, and their meals are always fully cooked. They have never been served under cooked food. Some have even requested more food; the staff always brings them 2^nd. The food is always good, they have no complaints. LPA reviewed the menu for 1 month. The menu has healthy and a variety of different meals on the menu for residents to choose from. LPA observed the food being served for lunch. The food potions were enough. The food was hot and cooked. The pan that had the meat cooking was sizzling and steam was coming from pan. The pot with the vegetables had the water boiling and steam was coming from the pot. The interviews, records, and observations do not concur with the above allegation.

An exit interview was conducted with Jean De Guzman, Director of Health Services and a hard copy of report was provided.