Complaint Investigation Report

Allegation: Facility staff did not follow resident’s dietary restrictions

The allegation alleges that a resident has a prescribed diet of no-sodium, and staff provide them food containing salt, garlic, and other seasoning.

During the facility tour, LPA observed on the board a Resident Dietary Information form posted for R1 that states a Special Diet of No Added Salt and has a Food Dislike of spices. LPA observed in the kitchen a clip board hanging that has the Dining Room Log that lists the Residents and Modified Diet. LPA observed R1 listed and under Modified Diet has No Added Salt, No garlic, and No onion.

LPA reviewed a Medical Assessment dated 04/08/2025, that does not indicate R1 requires a special diet. Additionally, a Physician’s Report dated 03/19/2025, for R1 was reviewed and does not indicate R1 requires a special diet.

LPA received and reviewed a Diet Clarification Request dated 08/08/2025 that indicates R1 is to have a “No added salt” diet.

During interviews with Staff S1–S6, were asked if residents dietary orders and preferences are met, six (6) out of six (6) stated yes, resident dietary orders and preferences are met.

During interviews with Resident R1-R8, were asked if staff follow their dietary order or dietary preferences, eight (8) out of eight (8) stated yes their dietary orders and/or dietary preferences are met.

Allegation: Facility staff did not adequately prepare resident food

The allegation alleges a resident was provided with garlic shrimp and the shrimp was rinsed in water to remove seasoning.

LPA received and reviewed a photo of the order taken from Resident R1. The order is dated 10/09/2025 at 5:49pm. Resident R1 first initially ordered Special 1 at 5:40pm that was a chicken meal. During an interview with Staff S4 stated Staff S5 came down to change the order for R1 to Special 2 that consisted of Garlic Butter Shrimp with lemon parsley sauce. Staff S5 informed Resident R1 the shrimp was cooked in a garlic butter and was instructed to rinse the seasoning off the shrimp. On the order for Special 2 with the instructions to “rinse with water.”

LPA reviewed a copy of the Nutricopia Consultant Dietitian Repot Card for Assisted Living (dated 09/2025) that indicates staff have “adequate training/orientation of staff,” “in-service training monthly and informal education as needed,” and “Food Service staff have Food Handler’s cards.”

LPA received and reviewed the Relias Transcript for all kitchen staff. LPA observed all kitchen staff had completed the following training on Relias The Basics of Nutrition and Food Safety, Food Safety Fundamentals, and An Overview of Safe Eating and Drinking. LPA observed all kitchen staff have a current