Complaint·March 6, 2025

LIC9099-C (Page 2) Allegation: Staff did not use food service sanitation practices to protect the resident's food from contamination. Finding: Substantiated On 03/03/2025, LPA L. Alexander interviewed witnesses (W) W1 and W2. W1 stated that on 02/01/2025 the facility served fish and that the fish was undercooked. W1 stated that the fish was baked, and it was cooked on the outside but when they used their knife to cut into the fish it was uncooked. W1 stated that they returned the meal back to the caregiver. W2 stated that on 02/06/2025, Resident (R), R1, told them that the chicken was raw and that they didn’t eat it. W2 stated that they observed that protective gloves are not worn when preparing meals. W2 stated the meals are not nutritious nor well prepared. Both W1 and W2 stated that lunch and dinner are served at around 11:30am and 4:30pm. On 03/05/2025, LPAs L. Alexander and K. Nguyen interviewed fifteen (15) residents (R). R6, R9, R13 stated that they have been served raw food before, the food is not good and most times food is served cold. R2, R3, R4, R5, R6, R7, R8, R12, R14 and R15 all stated that the food is not good and is served cold. R9 stated that the food is okay. R11 stated that they’re on a modified diet. Therefore, they haven’t experienced the quality of food temperature and taste of the food served. On 03/05/2025, LPAs L. Alexander and K. Nguyen toured the kitchen around 11:50 am and observed four (4) staff (S) members in the kitchen preparing food and prepping food on trays to serve the residents. LPAs observed S1 stirring food in a pot with just one (1) glove on and the three (3) other staff were not wearing gloves or protective hair nets while handling food and food trays. LIC9099-C (Page 3) At around 12pm three (3) out of the four (4) staff that were in the kitchen started to place protective gloves on their hands. LPAs observed S2 handling food, then handling paper menus with the same gloves on. At around 4:39 pm LPAs observed three (3) staff members in the kitchen prepping food to serve residents for dinner who were not wearing protective gloves nor hair nets on their heads. LPAs observed two (2) other staff serving dinner plates to the residents in the dining area who were not wearing protective gloves. LIC9099-C (Page 5) Allegation: Staff retaliated against resident for complaining Finding: Unsubstantiated On 03/03/2025, LPA L. Alexander interviewed witness (W) W1. W1 stated that on 02/08/2025 they went to the kitchen and knocked on the door three times and on the third knock S2 opened the door with an attitude. W1 further stated that S5 was told by S4 that R1 was not served their lunch tray and that S5 said “I don’t care.” W1 stated that it feels like retaliation from some of the staff caregivers. W2 stated that they felt retaliation if they complain about something. On 03/05/2025, LPAs interviewed R2. R2 stated that they have heard S4 being rude to R1. R2 stated that R1 yells at staff. R3 thru R15 all stated that they do not have any trouble with the caregiver staff. R3 thru R15 all stated that they get good care from the caregivers and that they have not felt any type of retaliation. R3 thru R15 all stated that they have not heard any of the staff caregivers speak of any residents in a negative way that would suspect retaliation. On 03/06/2025, LPA interviewed S2. S2 stated that they do not talk to R1 due to previous issues. S2 stated that R1 chooses not talk to with them. S2 stated that S3, S4, S5 and S6 all have expressed frustration because R1 is always complaining to or about them. S2 stated denial of retaliation towards R1 but they just won't be talking to them anymore. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.