Complaint Investigation Report

The allegation of “Staff did not meet a resident's dietary needs” alleges that the facility did not adhere to the dietary restrictions of resident #1 (R1). LPA Byrne interviewed R1 who stated that they are lactose intolerant and facility staff are aware of this dietary restriction. R1 stated that they were given cereal with milk by staff #1 (S1) on the morning of 05/08/2025. R1 stated that as a result of consuming the cereal and milk the suffered an episode of diarrhea for a few hours. LPA interviewed S1 who admitted to giving R1 cereal with milk in the morning of 05/08/2025. S1 stated that they were aware that R1 cannot have milk due to their lactose intolerance. S1 stated that R1 had a total of three (3) bowel movements between 09:15 AM and 10:15 AM after being given cereal and milk. S1 stated that they informed the responsible party of R1 immediately and offered their apologies for the incident. LPA interviewed staff #2 (S2) who confirmed that R1 had 3 bowel movements on the morning of 05/08/2025. S2 stated that they assisted in changing R1 and described the bowel movements as normal. LPA interviewed the Administrator who stated that they were unaware of R1’s lactose intolerance or R1 being given milk with cereal. LPA requested that the Administrator submit an incident report to Community Care Licensing for this incident, the Administrator agreed to submit an incident report. LPA interviewed two (2) additional residents. One (1) resident interviewed, resident #2 (R2) had a dietary restriction. R2 stated that the facility adheres to their dietary needs. R2 had no concerns about the facility’s food service. Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Staff did not meet a resident's dietary needs.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.