Complaint Investigation Report

Allegation: Resident’s dietary needs were not met. R1 was not to eat pork due to religious reasons. Staff interviewed acknowledged that a plate containing pork was served to the resident, but no staff interviewed stated that R1 ate the food. There were text messages between the private caregiver and the POA which stated that the food looked different. The cook and Dietary Supervisor who were interviewed stated that this meat was chicken, not pork. Additionally, the private caregiver acknowledged that R1 did not eat pork while she was with her at the facility.

Allegation: Resident’s hygiene needs were not met. Based on staff interviews, R1 was frequently resistant to care. R1, at times, would become combative with staff. LPA reviewed R1’s progress notes which detail staff attempting multiple times when R1 would refuse personal care or showers. All facility caregivers and med techs interviewed acknowledged that R1 would, at times, resist care, however there were always repeated attempts.

Allegation: staff falsely documented records regarding resident care. LPA reviewed R1's physicians report, care plan, and progress notes. Progress notes which detailed R1's refusal of showers/personal care and behaviors were date stamped and LPA did not observe any late entries. Physicians report and care plan were noted to be current and in compliance.

Allegation: staff left resident outside unsupervised. LPA obtained a picture of a resident appearing to be asleep, outside in the sun. Staff interviewed acknowledged that when the weather is nice, the courtyard doors are open and residents are free to go out to the courtyard. Staff interviewed stated that residents are not outside unsupervised for extended periods of time. While LPA did obtain a picture showing a resident outside, sleeping in direct sunlight, LPA was unable to determine the length of time resident was outside.