complaint·March 11, 2026

Allegation: Staff do not ensure resident’s privacy. The reporting party (RP) stated that at night around September 2025, resident (R1) was going to the big building in the facility to take a shower, and R1 observed staff (S2) giving bath to resident (R2). R2 was naked and the bathroom door was open while S2 was giving R2 a bath. All residents except R1 stated not observing any staff giving bath to residents with bathroom door open. R1 stated observing S2 giving bath to R2 one night with bathroom door open. One of the staff does not provide care giving while the other one stated not providing assistance with bathing to residents. S2 who works NOC shift stated he does not give bath to residents including R2 at night and that residents are given bath during the day. The rest of the staff interviewed indicated when they provide assistance with bathing they close the bathroom door. Due to medical condition, LPA was not able to obtain information from R2. Therefore, the allegation is close as unsubstantiated. Allegation: Staff are not meeting residents’ dietary needs. The reporting party (RP) stated R1 has been forced to eat meat but due to religion, R1 cannot eat meat or use animal products due to R1 itches when eating and/or touching animal products. Review of records showed R1 was seen by a doctor due to itching but After Visit Summary didn’t indicate to avoid and/or not eat animal products. LIC602A Physician’s Report didn’t indicate any food allergies or other type of allergies. On 10/07/25, R1 stated that when he moved-in, he told the staff that he prefers vegetarian food but he turned vegan around 10/2025, because whenever he eats something with meat and meat bi-products, he itches. At first, the staff told him 'maybe' and later was offered vegetarian diet but it's not totally vegetarian because they still put meat on it. Around first week of October 2025, the cook told him he can buy his own food and the cook will prepare for him b ut S7 told him that he should no t be bothering the cook which S7 denied telling R1. ........continued on 9099C On 11/04/25, R1 stated the staff are good and serving him vegetarian meals. LPA conducted inspection of the kitchen and observed list of residents who are on soft diet and those with food preference but no list of residents who are vegetarian or vegan. The cook stated he does not have list but he knows because there's only 2 of them. He stated R3 is vegetarian due to religious/spiritual belief and he does not serve R3 meat. He further stated that he himself is vegetarian, so whatever he prepares for himself, he serves to R3. He also stated that R1 use to eat meat before but around September 2025, R1 transitioned to vegan. On November 2025, R1 told him that he's not eating meat so he prepared him vegetarian meals for about 5 days, but after 5 days, R1 told him that vegetarian diet is not working, so R1 started eating meat again and asked him for hot dog. When R1 told him he is vegan, he served him vegan meals. R3 stated staff do not served him meat. Based on interviews and records review, the allegation is unsubstantiated. Allegation: Staff do not ensure residents are accorded dignity. The reporting party (RP) stated that when staff (S3) was putting 'apron' on resident's (R2) thigh while in the dining room during meal, S3 touched R2's thigh and was not mindful. R1 stated it bothered him and does not think that the touching was accidental. S3 confirmed she puts an apron like a bib and ties it on R2's neck and the apron stretches up to the lap. S3 denied touching R2's thigh when placing the apron. Due to medical condition, LPA was not able to obtain information from R2. Therefore the allegation is unsubstantiated. Based on interviews, records review and inspection, the 3 allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.