- Date
- 3/3/2025
- Report number
- 00387019-AP-354405
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Description of Incident Under the prior ownership: Modified diets including specialized diets ordered by a health professional have to be provide by the facility. Kitchen staff have been trained on specialized diets and have references to help them understand each diet. There is a whiteboard in the kitchen where all the residents’ names, room numbers and dietary needs are listed. Residents on specialized diets have blue plates, and only these residents get the colored plates. Kitchen staff refused to get thickening powder for a resident who had an order for thickened liquids. The kitchen staff have had issues with the minced and moist and other specialized diets on multiple occasions. Residents have been served food that is incorrect for their specialized diet. Care staff have to frequently check meals to ensure that residents are getting the correct texture diet. Kitchen staff do not follow the dietary guidelines or service plans. The kitchen staff do not have any methods for quality control. The facility failed to provide a safe environment, have oversight over kitchen staff, and failed to follow the service plans of Alleged Victim (AV) and other residents, which is a violation of resident rights, is considered neglect of care and constitutes abuse.