complaint·September 5, 2025

Interview with Staff #1 (S1) at 9:15 a.m. on 06/17/25 revealed that after each of R1’s hospitalizations, doctors wrote new orders. They changed one capsule medication to a liquid then changed it back to a capsule days later. Interview with the administrator at 1:20 p.m. on 06/17/25 revealed that despite R1’s frequent hospitalizations and subsequent medication changes, staff always followed all physician orders and updates. Record review of R1’s medication list revealed medication changes on 06/02/25 and 06/10/25. Record review provided no other pertinent information about R1’s medication procedures. Staff training records indicated all staff received training for R1’s special health care needs. Based on interviews and record review, facility staff properly provided medication assistance. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Facility staff do not follow modified diets " it was alleged staff served all residents the same food and did not follow modified diets. Record review of residents’ medical assessments revealed that zero (00) out of six (06) residents had modified diets prescribed by a physician. Review of R1’s medical records revealed R1 “states that [they have] dysphagia, but [they don’t. They] passed swallow evaluation”. Additionally, R1’s records indicated normal Gastrointestinal functioning. Interviews with five (05) out of six (06) residents revealed they enjoyed the food served in the facility. Interviews with two (02) staff and the administrator confirmed no residents have modified diets. Staff and the administrator confirmed that all physician orders are followed. Staff noted all residents are served three (03) meals a day and snacks. LPA observed breakfast service today at 9:00 a.m. and lunch service at approximately 12:00 p.m. on 08/19/25. Meals served to residents contained a nutritious variety of fruits, grains, proteins, and liquids. Food was served in a safe and healthful manner. Based on observations, interviews, and record review, staff serve appropriate meals to residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.