Complaint Investigation Report

S2 stated that there had been no service plan in place to provide feeding assistance to R1 when R1 first moved into the facility; however, staff still assisted R1 with feeding. S2 stated that the service plan was updated on April 27, 2025, to include feeding assistance for R1, but POA did not sign the updated plan. S2 further stated that on 04/27/2025, when R1 felt dizzy, R1 had finished their dinner. Snacks were provided between 6:30 and 7:00 PM and were available to residents both day and night. S5 stated that they had assisted R1 with feeding during breakfast and lunch, as well as with showering and changing clothes. S5 reported that R1 ate pureed vegetables and fruits, along with yogurt, served on a three-compartment plate. R1 ate very slowly, and some food would spill from their mouth, but R1 would finish their meals. S5 stated they were responsible for feeding two residents, including R1, during mealtimes in the dining room. S6 stated that they worked the evening shift and would bring R1 to the dining room to feed dinner, which consisted of pureed foods, along with assisting one other resident at the same time. S6 reported that R1’s meals typically included items like yogurt, mashed banana, and dessert. R1 ate slowly, and some food would spill while R1 was eating, but R1 would finish the entire plate within 30 to 35 minutes. S6 stated that R1 never requested any snacks or additional food after dinner. S6 further stated that they had fed R1 dinner on the day 911 was called. S6 recalled that after dinner, R1 went upstairs, and it was R1’s roommate (R5) who pressed the call button when R1 began feeling unwell.

R3 stated that they had received three meals a day and snacks in between. R4 stated that they ate breakfast and dinner but did not eat lunch or snacks frequently. R5 stated that they remembered R1 as their roommate. R5 further stated that R1 appeared to have difficulty with swallowing, as food would often spill from R1’s mouth, and staff assisted R1 with eating mashed food. R5 stated that R1 experienced a heart attack and was sent to the hospital.

On 05/27/2025, LPA interviewed R1’s Power of Attorney (POA) / Reporting Party (RP). POA stated that they had observed signs of neglect in December 2024. POA reported that R1 required one-on-one assistance with feeding, but there were no staff available to assist R1 with feeding whenever they visited the facility. POA stated that feeding assistance was the primary reason for admitting R1 to the facility. POA further stated that they did not have any documentation confirming that R1 would receive one-on-one feeding assistance at the facility or outlining any specific feeding arrangements that had been agreed upon. However, POA mentioned they had informed the facility’s sales coordinator, who was no longer employed there, that R1 needed to be fed. POA also stated that R1’s Primary Care Physician (PCP) had expressed concerns about R1’s weight loss and had indicated PCP would speak to the facility regarding R1’s feeding needs.