Complaint Investigation Report

malnourishment. During LPA’s visit, it was observed that facility offers a well-balanced, nutritious, and edible meals throughout the day with various options. During interviews with staff, all staff stated they not only fed the residents and provided the same meals as everyone else but also purchased additional food according to R1’s preferences and dietary restrictions. During interviews with residents, all residents stated they are served three (03) meals a day and that snacks are available throughout the day. During an interview with a third-party, they stated that residents loved to eat and did not suspect any malnutrition or inconsistencies while visiting the facility. A review of the Physician’s Reports, admission agreement records, and hospital discharge documents did not indicate that the resident was malnourished.

Based on interviews, observations, and record review, there is not enough information to verify the allegation. Therefore, the allegation is Unsubstantiated at this time.

Allegation #2: Staff did not prevent resident from becoming dehydrated.

During LPA’s facility tour, it was observed that a cup of water with a straw is available beside the residents’ bedside table. Interviews conducted with the administrator and staff during the initial visit revealed that they always keep water next to the residents’ beds and that R1 was drinking fluids regularly. A review of medical records from the hospital did not reveal any information to verify that at the time of admission to the hospital, R1 was dehydrated.

Based on observation, interviews, and record reviews, this allegation is deemed Unsubstantiated at this time.

Allegation #3: Staff initiated hospice care services for resident without authorization.

It was alleged that Resident #1 (R1) was placed on hospice care without their authorization or knowledge. LPA phone interview with R1’s Power of Attorney (POA) at 3:00 PM on 7.1.2025 revealed that R1’s POA was aware of what they had signed and was advised on the services that hospice will provide.