Complaint Investigation Report

9099C1-. Allegation: Staff are not following physician's order . T he allegation states that staff are not following resident (R1’s) dietary plan, including serving soft foods and cutting food in small bites, and with serving too many Ensure drinks at a time.

The family member stated she signed the care plan which notes (R1) has "aspiration precaution, is at risk due to crackers", the caregiver stated (R1) can swallow Ramen noodles fine, and they are not cutting them; however, resident's Home Health provider said to cut the food in small pieces, and they only do sometimes. The family member stated one time when she visited, (R1) was eating a whole Persimmon, and the facility is "not following orders for aspiration as they gave him ice-cream last Thursday (1/15/2026), and they are supposed to put thickener in it". Additionally, staff are "supposed to cut bite sized sandwich pieces and they gave it to (R1) whole", staff gave (R1)(6) Ensure drinks in one day" due to being "combative". The family member commented that due to (R1) being at risk for sugar, she told staff (R1) should have no more than (3) Ensure drinks each day.

On 1/20/26, Staff (S1) confirmed (R1) has "swallowing concerns" and she/staff use "thickener", showing LPA the bottle. Charting notes from 12/9/2025 note there is an order for (3) bottles of Ensure per day, and to continue thickening all liquids. (S1) stated "Yes, I do go over 3 per day because I don't want to be in an argument with him". On 1/20/26, LPA observed all residents to be served a whole sandwich cut diagonally, and (R1) to be eating their soup first. LPA asked (S1) about cutting (R1's) sandwich into bite sized pieces to which (S1) replied "(R1) can eat bites" but agreed to cut the sandwich, adding 'it doesn't have to be bite sized" and commented that (R1) "has improved " and the Speech Therapist did a reassessment and (R1) tends to not chew and just swallow" and stated he hasn't choked in a long time".

On 2/23/26, (S1) stated (R1's) diet consists of "regular to soft foods and staff do cut food for him as well as place thickener in all his liquids". Charting notes made on 12/2/2025 and 12/9/2025, document the instructions from Speech Therapists for swallowing safety as: “All foods must be soft and in bite size”.

The Administrator stated "staff is cutting it in small pieces- they will puree it if the food is tough to eat, such as a steak, and commented (R1) "always eats in a hurry" and on the discharge paperwork (dated 7/25/25), the diet states to cut it in bite sized pieces. (R1's) Care Plan notes resident is at risk for choking and states resident requires supervised eating/drinking and monitoring, encouragement and/or cueing and resident is prescribed a “mechanical soft diet”.