Complaint Investigation Report

On 04/21/2025, it was alleged that a resident was unable to eat the food served due to the resident's dietary restrictions. It was reported that the facility maintains a record of residents’ special dietary needs; however, it does not consistently follow them. It was also reported that the facility does not have a dietitian. The facility does not provide substitutions that residents can eat on a regular basis. Although the facility uses meal menu slips for residents who are unable to make their way to the dining hall, staff have at times forgotten to pick up residents’ meal slips from their rooms, resulting in residents not receiving meals on multiple occasions. It was reported that on 04/20/2025 at 9:30 p.m., a male resident with dementia entered a resident’s room without permission while the resident was sleeping. The resident woke up, yelled at the male resident to leave, and pressed the pendant for assistance. The staff responded within three minutes and removed the male resident.

Allegation: Staff do not ensure residents' dietary care plan is being followed.

On 04/28/2025, the Department interviewed staff members 1-2 (S1-S2) and residents 1-10 (R1-R10) regarding the allegation. Staff members (2 out of 2) and 9 out of 10 residents stated staff does ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to the physician-prescribed dietary menu, and residents are served well-balanced, nutritious meals according to the doctors' orders. S1-S2 and R2-R10 stated that the facility does have a dietitian. R1 stated that staff do not ensure residents' dietary care plan is being followed. S1-S2 and R2-R10 all denied the allegation.

Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day.

On 04/28/2025, the Department interviewed staff members 1-2 (S1-S2) and residents 1-10 (R1-R10) regarding the allegation. Staff members (2 out of 2 ) and 9 out of 10 residents stated staff does ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents confirmed they receive three meals per day, alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodates the request. R2-R10 stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. S1-S2 and R2-R10 all denied the allegation.