Complaint Investigation Report

Podiatric evaluation & treatment sheet dated 4/25/2025, residents service sheet from Holistic Healthcare Inc. dated 2/7/2025, and Notes. LPA also reviewed resident 1 - 5 (R1-R5) files for podiatry treatments dated 12/19/2024, staff roster, resident roster and letter confirming new service provider ROADS dated 6/24/2025. LPA also conducted Interviews with staff members staff 1- 3 (S1-S3), three (3) external witness 1- 3 (W1-W3), Resident 1- Resident 5 (R1-R5).

The investigation revealed the following:

Allegation: Facility staff did not ensure resident's podiatry needs were met.

At 9:00 AM, LPA reviewed R1's facility file and records, which revealed that R1 had been assisted with their podiatric needs within the past 6 months. However, LPA observed documents showing that R1 refused care at the time of the physician’s visit.

At 9:45 AM, LPA conducted interviews with three (3) staff members (S1-S3), and 3 out of 3 staff members stated R1 was being assisted with their podiatric needs while in care, but R1 had refused services at the time of the physician’s visit, Alternative measures were put in place for a podiatrist referral and office visit prior to R1s relocation. Staff also stated services are provided on a quarterly basis and they are currently waiting for podiatric evaluation & treatment service forms for the month of April 2025.

LPA Allen conducted interviews with three external witnesses (W1-W3). 3 out of 3 witnesses confirmed they had been informed by staff about R1's podiatric needs and were aware of R1's prior refusal of services and understood that additional measures were being implemented to address these needs.

LPA attempted to interview resident 1 (R1) on 6/4/2025 who was unable to have a clear conversation. R1 was not able to confirm or deny that podiatric services were provided or not.

On 6/19/2025 LPA Allen, LPA conducted interviews with resident 1 - 5 (R1- R5) of those interviewed 4 out of 4 stated the doctor comes to the facility and provide podiatric needs about every 2-3 months. LPA also observed Evaluation & Treatment sheets dated 12/19/2024. As of April 2025 the podiatrist company has been changed from Valley Community Multi-Care Service, Inc. to R.O.A.D.S Community Care Clinic for R2-R5) and documents reflect if services were been provided for R2-R5. Continue......