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32 | This page is being amended due to identifying and additional information received by the Department.
Allegation 1: Staff did not ensure resident’s dietary needs were met.
On 02/06/2026, LPA interviewed reporting party 1 (RP1), who reported concerns that while resident 1 (R1) resided at the facility, staff provided canned, frozen, pre-packaged, and restaurant foods rather than meals consistent with R1’s dietary needs.
On 01/06/2026 and 04/16/2026, LPA interviewed six staff (S1, S2, S3, S4, S5, and S6). S1 to S6 stated that meals were prepared and offered to R1 consistent with the facility meal plan, R1’s dietary needs, and nutritionist recommendations; however, R1 frequently refused the prepared meals and requested alternative food choices when R1 did not like the food offered. S1 to S6 stated that when R1 refused prepared meals, staff would ask R1 what he/she would like to eat to encourage food intake. S1 to S5 stated that staff would take R1, with the responsible party, to purchase grocery items at least once a week based on R1’s preferred food choices that met R1’s dietary needs. S1 stated that R1 may request to order outside food, which was paid for by the facility. R1 had discharged from the facility on 12/31/2025. On 01/06/2026, LPA attempted to interview R2 and R3; however, R2 and R3 were non-verbal, non-ambulatory, and tube fed, and were unable to participate in interviews.
Based on record and document review conducted on 02/09/2026, records documented that R1 has documented medical conditions requiring specialized medical care need device and dietary management. A nutrition assessment dated 08/06/2025 documented that R1 was able to express wants and dislikes and frequently requested restaurant foods. Facility provided proof of purchase dated 02/18/2025 through 10/01/2025 for various restaurant and grocery food purchases for R1. S6 stated that the facility met with R1’s responsible party on 08/26/2025 due to concerns that R1’s refusal of facility prepared meals and frequent outside food requests could impact R1’s dietary plan. Record review documented that R1 did not maintain incidental funds at the facility.
see LIC 9099C
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