Complaint Investigation Report

R1’s Needs and Services Plan and Appraisal both showed that R1 needed help with bathing, dressing, toileting, and moving around, and that he sometimes became confused.

Hospice records showed that nurses and home health aides visited R1 periodically and provided wound care, changes, catheter care, and hygiene support. The subpoenaed hospice documents confirmed that R1 already had pressure sores and other injuries before moving into the facility.

The administrator (AD) stated that R1 came into the facility with the sores and that hospice was notified right away. AD also explained that R1 sometimes refused to be changed, and staff would encourage R1 when this happened. Staff interviewed denied leaving residents in soiled diapers and said they changed residents as needed.

Based on all the information gathered and reviewed, the preponderance of evidence of standard is not met. Therefore, the allegation that the facility caused R1’s pressure injury or failed to prevent it was UNSUBSTANTIATED

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The investigation into the allegation that staff are serving cold meals to residents consisted of LPA reviewing screenshots of group text messages between the administrator and several staff members. The messages showed routine communication about daily tasks and short notes about residents, including a handwritten list of food items. However, the screenshots did not include any comments about food temperature, or any complaints from residents or staff about cold food. There were no time stamps, and no information showing how meals were prepared or served. Because of this, the screenshots did not provide evidence to support the allegation.

The LPA also interviewed staff on duty (S1) on 6/4/25, which they stated that the facility does not serve cold meals unless the food is supposed to be cold, such as sandwiches. S1 explained that meals are served warm and that they have not seen staff give residents cold food.

During an interview with Administrator Chukwudi Patrick Ikiseh (AD), stated that the facility does not serve cold meals unless the menu calls for a cold item. AD explained that staff often send him photos of the food they prepare, and he monitors meal quality through these messages. He said there have been no complaints from residents about cold food.

Based on the information gathered, the preponderance of evidence is not met. Therefore, the allegation is UNSUBSTANTIATED.