Complaint Investigation Report

Allegation: Facility fails to provide residents with a nutritious diet. It is alleged that the facility does not have sufficient fresh food and residents are primarily served highly processed foods i.e. bologna, hot dogs, and frozen food meals that are not nutritious. Based on observation, the findings indicate the facility food supply is primarily based of frozen prepackaged food items and/or meals like waffles, chicken breast patties, bologna, sausage hot dogs, frozen cheeseburgers, frozen vegetables, cheese, eggs, canned foods, and fruit juice punch. The facility had low supply of fresh fruit and vegetables, and fresh protein food items. Due to insufficient fresh food, today's menu items have been substituted with other food frozen food items. Resident files were reviewed. Per Physician Report, two (2) out of four (4) residents have hypertension and have physician orders for pureed or mechanical soft diets. Additionally, the facility's emergency water supply is not being replaced and there is very little water supply for residents. A total of (3) staff were interviewed all confirmed that there is currently no emergency water supplies in storage. Facility protocol is to have a minimum of two (2) gallons of water per resident. The facility has an approved General Healthful Die (GHD) food menu created by a Registered Dietician that states: "This GHD is also consistent with the heart healthy, low fat, low sodium and consistent carbohydrate diet)." Therefore, there is evidence to prove that the facility has insufficient fresh perishable foods for a minimum of two days.

Allegation: "Facility ran out of diapers for residents in care." It is alleged that the facility ran out of incontinence resident diapers many months ago and staff has had to buy supplies with their own money, and/or bring supplies from other facilities in order to meet the resident's incontinence needs. Based on interviews conducted residents (R3 & R4) are incontinent and require 5-6 diapers per day. Resident (R1) does not use incontinence diapers, and resident (R2) uses incontinence pull-ups. The facility is supposed to renew the incontinence supplies contract yearly so that supplies are delivered monthly. However, the renewal referral was not submitted in late 2021 by previous Administrator. As a result, the facility has been using surplus supplies from other facilities. During today's visit, only incontinent liners were observed to be sufficient. The facility only has one case that contains 4 packs of 10 diapers; which is not sufficient to meet the incontinence needs of the residents. Per Administrator, an incontinence supply referral to J & B Medical was submitted on September 22, 2022.