Complaint Investigation Report

Allegation: Staff did not ensure that resident was adequately fed

It is alleged that resident was not eating and as a result R-1 had lost a lot of weight Per staff interviews and a review of the Admission Agreement LPA Felisa Shirley observed that there are three meals and three snacks served daily which are included in their monthly fee. Per interview with S-2, caregivers will assist if they notice that resident is not eating and will offer alternatives if desired. LPA Shirley toured the inside and outside grounds of the facility. LPA Shirley observed residents eating in the dining area and LPA Shirley did not observe food being served is not of good quality. LPA Shirley reviewed residents service file and Physician’s Report and observed that R-2 had a regular diet. Per Preplacement Appraisal Information, R-1 feeds self independently. LPA Shirley observed R-1’s Narrative charting and observed that R-1 sometimes ate only 50% of his meal and sometimes refused to eat because he didn’t want to gain weight. LPA Shirley reviewed R-1’s weight chart and did not observe a drastic weight loss.

LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, does staff monitor residents during meals ensuring that residents are adequately fed. Of those interviewed, 5 out of 5 staff answered yes. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, do you get enough food and are you allowed seconds if desired? Of those interviewed, 4 out of 4 answered yes. R-1 was not available.

Allegation: Staff did not meet resident’s toileting needs

It is alleged that staff were not changing resident as needed. LPA Shirley reviewed R-1’s Resident Daily Activities of Daily Living Sheet and log of incontinence care for the AM and PM shifts from January 2024 thru August 2024. LPA observed that there were entries on log sheet for incontinence changing on a consistent basis.

LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, is there a schedule for incontinence needs and if resident’s needs were being met. Of those interviewed, 5 out of 5 staff answered yes. LPA interviewed Resident-2 thru Resident-5 (R-2 thru R-5). LPA asked, are your incontinence needs being met? Of those interviewed, 2 out of 4 answered yes, and 2 stated that they were good on their own. R-1 was not available.