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diet of puree thickened liquids and was Bedridden. The Resident Appraisal dated on 2/14/2022 noted Resident #1 (R1) arrived with a G-tube and received hospice services. The hospice nurse came one to three times per week, and the home health aide visited twice per week. Resident passed away on 2/12/2025 but was interviewed by the Department on 8/22/2023.
It was alleged that Resident is left in bed for an extended period of time. LPA reviewed Physician's Reports from 2/15/2022 and 1/18/2023 which reported R1 was bedridden. Interviews with three of three staff stated that R1 was only able to be out of the bed and in a wheelchair for approximately fifteen minutes. Interviews with two of two witnesses stated R1 did not want to be out of bed and was comfortable. Both witnesses stated that the resident resided in the facility for three years and never had bedsores the entire three years. Staff constantly repositioned resident every two to three hours. Three of three staff and two of two witnesses denied the allegation. LPA interviewed three of three residents and all denied the allegation that they were left in bed for an extended period of time. One resident stated they cannot move about freely but staying in bed was a choice and that staff encourage the resident to get outdoors.
LPA investigated the allegation that Staff is not meeting resident's dietary needs. Per Resident Appraisal dated on 2/14/2022, R1 had a G-tube, which was managed by hospice. Family and Power of Attorney (POA) visited often and would also assist with feeding R1. Per Physican's Report dated 2/14/2022; R1 was on a special diet of thickened, pureed foods due to a secondary diagnosis of Dysphagia. Interviews of three of three staff and two of two witnesses denied the allegation that Staff is not meeting resident's dietary needs and stated resident readily ate. Three of three residents were asked about food and dietary needs being met and three of three residents stated there is plenty of food and their dietary needs were being met.
Lastly, it alleged that Staff do not treat resident with dignity or respect. Three of three staff and two of two witnesses reported that there were multiple visits by the Orange County Sheriff and paramedics. During one such visit, the Power of Attorney (POA) was present and asked who had called for emergency services since the POA did not request these services. Staff stated that if resident was asleep and did not answer the phone, that paramedics came and were told resident was unconscious; when in fact resident was asleep and was being visited by POA. R1 had a hard time holding the phone to FaceTime others and had difficulty
(Continued on LIC 9099C-1)
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