Complaint Investigation Report

9099C-1. Allegation: Staff do not provide the foods necessary for resident's special diet. The allegation states staff has not purchased resident (R1) almond milk and are not serving foods (R1) can eat.

The Administrator and another care staff stated to LPA, on May 22, 2026, that (R1) follows a special diet that does not include dairy or gluten/wheat. Both of these staff stated the facility orders specific food for (R1), who also shops on their own, with one staff confirming she drives (R1) to the store. LPA observed (2) half gallons of dairy free unsweetened almond milk in the refrigerator on May 22, 2026. One of the half gallons was almost empty and was dated May 7, 2026. The second half gallon had not been opened. Staff showed LPA where (R1) keeps her food in the refrigerator/freezer, and on the shelf. LPA observed a frozen loaf of Gluten Free bread (100% whole grain) that was marked "Dairy, soy and nut free" on the packaging. Additionally, staff showed LPA where fruit and meat on hand for (R1) were located. LPA observed (2) types of dry cereal (Chex and Cheerios). Both cereal boxes were marked "gluten free". LPA observed each resident's "Special Diet" to be posted on the outside of the refrigerator.

A third staff stated on June 4, 2026 that staff has consistently followed (R1's) special diet and the "diet sheet" for all residents is posted on the refrigerator. This staff stated (R1) will typically eat fruit and cereal for breakfast, fruit, vegetables and smoked turkey for lunch, and often has fruit, chips, potato bread and burgers (without cheese) for dinner. This staff confirmed that the facility "always has" Almond Milk on hand.

LPA interviewed (3) residents. Two residents stated they will tell staff what they can't eat prior to the meal, and staff will follow that. A third resident stated there haven't been too many times when staff served something he couldn't eat, but when they did, staff will offer an alternative food. This resident stated he does not have any allergies and staff will document what they serve.

Resident (R1) stated on June 1, 2026 that staff are "now" giving them the correct foods. On June 4, 2026, the staff showed LPA food on site for (R1), including cereal, fresh fruit (bananas, cantaloupe, berries), (1) unopened half gallon of Almond Milk, (2) kinds of deli meals, spinach/lettuce, and frozen bread and frozen vegetables.

The facility was previously cited on April 22, 2026 for not following (R1's) special diet.

Based on observations made, documentation reviewed, and interviews conducted, the allegation is found to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.