complaint·December 29, 2025

Allegations: “Resident was not accorded dignity and respect” and “Staff withheld food from Resident” It was reported that Staff #1 (S1) did not treat Resident #1 (R1) with respect and withheld food. Resident interviews revealed that S1 is generally respectful and has not been observed to yell. They reported that R1 often engages in conflict with staff, including following them around the facility and raising their voice. Residents noted that while R1 and S1 have daily disagreements, S1 typically responds by reminding R1 of facility policies. Residents also reported that they have not experienced food being withheld, even when arriving late to mealtimes. They indicated that when R1 arrives late, they sometimes request multiple meals at once, which can delay kitchen staff in completing other duties. R1 expressed feeling that they must avoid conflict with S1 and stated that S1 treats other residents respectfully but not them. R1 was unable to provide specific examples of disrespectful language. R1 acknowledged calling staff derogatory names when upset and videotaping staff interactions. R1 reported being late to mealtimes due to their health condition and initially claimed food was refused, but later clarified that meals are provided, though preparation may take additional time. Staff reported that R1 can be challenging to serve, often insisting on services according to their own preferences and timeline. Staff described R1 as frequently raising their voice and disregarding facility rules. Staff stated that S1 responds appropriately and does not yell at R1. S1 reported their role with R1 is limited to medication administration and that they do not engage further in R1’s behavior. Staff noted that R1’s videotaping of staff causes discomfort. Staff confirmed that although R1 is often late to meals, food is provided. Staff stated they anticipate R1’s tardiness and save meals or provide alternative options when necessary. Report Continued on LIC 9099-C Documentation indicated R1 has a diagnosis of Schizoaffective Disorder with mild cognitive impairment. The Appraisal/Needs and Services Plan dated 12/09/2024 noted periods of forgetfulness and non-compliance with dietary recommendations, with staff expected to provide reminders and simple instructions. R1’s Individual Program Plan (IPP) dated 06/02/2022 documented difficulty in understanding the consequences of actions, defensive reactions to feedback, and frequent arguments. The IPP noted disruptive behaviors interfering with social participation, with outburst occurring at least weekly, and included goals for R1 to work toward following facility rules and recommendations. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. The LPA discussed staff conduct and resident care needs with the ED to ensure continued understanding of resident behavior and appropriate staff responses. The ED acknowledged and understood. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.