Complaint Investigation Report

LPAs interviewed three (4) staff and two (2) of four (4) staff stated that C1 asked for tilapia. One staff (S4) was not working and unable to answer the question. S2 stated that each client has option to request any item for mealtimes and facility will honor it if possible.

On 06/03/2025, facility had tortellini on the menu for dinner, and according to S2, S2 stated that C1 asked for tilapia in the morning after S2 explained that tortellini ingredients option was not beneficial to C1 due to upset stomach C1 had. C1 stated C1 observed fish on the counter and asked S2 how long it had been on the counter, C1 stated C1 was afraid that fish was bad due to being on the counter for too long and refused to eat it and instead asked for the tortellini. S2 stated that is not correct. fish was thawed out in refrigerator. S3 stated S3 thinks that C1 ate the some of the fish but not sure. C2 stated C2 is not aware of the incident. There are no witnesses to corroborate the allegation of what occurred regarding the incident. All Staff denied giving C1 spicy soup and stated they threw away the spicy packet. There is insufficient evidence to substantiate the allegation.

Allegation: Staff mismanaged client's medication. It is alleged that C1 had stomach pain, and that facility did not provide C1 with Tylenol.

LPA interviewed four (4) staff, and three (3) of four (4) staff denied the allegation. Three (3) of four (4) staff stated they do not have a doctors order for Tylenol for C1 and cannot provide it to the client. S2 stated that C1 never asked for Tylenol, it was W1 who asked to give tylenol to C1.

There is no evidence to support this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated .