Complaint Investigation Report

The investigation revealed the following:

Allegation: "Staff are not following a resident's dietary plan. " It is alleged that C1 has a history of recurrent aspiration pneumonia and a G tube and should be on a pureed diet and have a choking care plan in place. However, despite C1's last release orders to be on a pureed food diet, C1 was given chopped food without an approval from C1's physician. Interviews conducted with staff and SC revealed that C1 was recently admitted in the facility on 09/14/2025. C1's restricted health care plan dated 09/14/2025 was reviewed and showed that C1 has a recurrent aspiration pneumonia with (2) hospitalization in the past 3 months. C1 was admitted to the hospital on 09/02/2025 for PEG-tube placement with discharge diet instruction for thin liquid and one-to-one feeding assistance with all oral intake. All (3) staff interviewed stated they have been giving chopped food to C1, because C1 had insisted, otherwise, C1 will throw a behavior. During the interviews, S1 told SC that a hospital nurse had verbally given permission for the chopped food, but in contradiction, S1 told LPA that the doctor from the hospital had verbally given permission for the chopped food. Additional documents reviewed showed that the training on PEG feeding care was given to staff on 09/14/2025. However, C1's behavior plan did not include any documented interventions. Furthermore, there was no medical documentation or doctor's confirmation instructing staff to provide C1 with solid or chopped food. Interview with SC revealed that the Regional Center is currently investigating this allegation and has not reached a conclusion. Documentation reviewed and interviews conducted corroborate this allegation.

Based on interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Omolola Oshodi, DSP along with the Appeals Rights. A copy of the report was also emailed to Henry Obi-Ijomah, Administrator.