Facility Evaluation Report

On 9/13/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Executive Director, Greg Klick .

On 3/20/23, the department received a complaint alleging R1's dietary restrictions were not followed for R1 and that R1 was not provided identified assistance while eating.

In addition to the investigated allegations Inspections, records and interviews found that in addition to the failure on the parts of S3 and S4 to properly prepare the food for R1 on 3/11/23, the investigation also found: S3’s and S4’s incid ents of, as their terminations letters state- “ multiple residents have received food that was not appropriately prepared”- had not been addressed in supervisor action prior to the incident on 3/11/23; that the procedures in place did not address individual meal verification when delivered to resident rooms; and that S1 was not provided appropriate training regarding R1’s dietary needs and assistance with cutting food. This constituted a failure on the part of the administrator to provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and need.

Furthermore, the incident report and death report provided by the licensee to investigators failed to be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified and did not include the nature of event and disposition of the case.