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- Plan Of CareCare planningOrder
Inspectors found that a resident with nutrition-related health concerns was served foods that did not match their prescribed diet on multiple occasions between November 2025 and May 2026. Staff did not follow the resident's documented diet plan, and delays occurred in notifying the home's dietitian of the resident's requests for other foods. The home has been ordered to train direct care staff on their duty to follow residents' diet plans and on the process for reporting dietary requests to the dietitian.
- Nutritional Care And Hydration ProgramsNutrition & diningOrder
Inspectors found that the home did not consistently monitor and respond to significant weight changes in residents as required by its own nutrition policy. Specifically, the home failed to initiate required reviews or obtain documented responses from the dietitian when residents experienced significant weight variances that met the home's own thresholds for action.
- Pain ManagementPain
Inspectors found that staff gave a resident pain medication on multiple occasions, but when the medication did not relieve the resident's pain (which remained above 8 on a pain scale), staff did not complete a formal pain assessment as required to better understand and address the ongoing pain.