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32 | R1 slept for most of the day.
During their last three months of life, R1 began to gradually eat less.
R1 had missing teeth causing them difficulty to chew. Staff had to cut R1’s food into small pieces.
R1 suffered from some type of muscle degeneration causing limit use of their fingers and hands.
R1 was sent to the hospital on 09/13/22 due to coughing phlegm. R1 also appeared to be listless.
R1 expired on 09/14/22.
Interviews and email contact with R1’s responsible person were made in May 2024. The following information were revealed:
Facility staff neglected to feed R1 during the last few months of R1’s life, which led to so much weight loss.
When R1 was admitted to facility, R1 weighed 101.5 pounds.
Five months prior to R1’s death, R1 weighed 71.4 pounds.
Because of Covid 19, responsible person wasn’t able to visit R1 much.
Email attachment of R1’s Certificate of Death received sent from Responsible person.
Certificate cited “Severe Protein Calorie Malnutrition”
Although R1 could not be weighed at time of death, R1’s estimated weight was approximately 80 pounds.
During phone conversation with R1, prior to September 13, 2022, R1 stated they don’t get fed at the facility.
Copies of hospital records were received and reviewed around May 14, 2024. Review of these records reveal:
R1 was admitted to the hospital on 09/13/22.
R1 admitted to the Emergency Room (ER) present with cough and congestion associated with low oxygen saturation.
Admission Diagnosis include protein calorie malnutrition.
Date expired 09/14/22 at 1155
Hospital noted R1 to be 107 years old and extremely frail.
Records also reveal R1 appeared to have been declining in a nutritional state for some time.
Based on the information obtained through interviews and hospital records, there is sufficient evidence to prove the allegations of Questionable Death, staff not meeting R1’s dietary needs, and staff did not seek |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/15/2024
Section Cited
CCR
87466 | 1
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7 | Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes. When changes such as weight loss or deterioration of a physical health condition are observed, the licensee shall ensure that such changes are docomented and brought to the attention of | 1
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7 | The facility has since closed, therefore no corrections needed at this time. |
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14 | the resident's physician. This requirement was not met as evidenced by: Interviews and record review reveal that since admission, R1 was losing weight since admission to time of death, but R1’s weight loss was not brought up their physician’s attention to address this concern. | 8
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Type A
10/15/2024
Section Cited
CCR
87464(d) | 1
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7 | Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs with those activities of daily living such as dressing, eating, bathing. This requirement | 1
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7 | The facility has since closed, therefore no corrections needed at this time. |
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14 | was not met as evidenced by: Information received reveal that R1 required assistance with eating due to missing teeth & muscle degeneration, that caused difficulty to eat, which caused R1 to lose weight. Records also reveal R1 had been declining in a nutritional state prior to death. | 8
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