Complaint·August 13, 2025

(Cont. from LIC9099) To investigate this allegation, LPA Rios interviewed the Administrator on 07/09/2025. The Administrator explained that the VSO had previously been teleworking and conducting resident meetings by telephone, which allowed residents the opportunity to discuss topics in private. However, the VSO has since transitioned to working from a cubicle and would schedule appointments in a small conference room when meeting with residents. During today's visit the Assistant Administrator informed LPA the VSO was no longer working for the facility and provided LPA a tour of the cubicles the VSO would have used when working at the facility. LPA Rios also interviewed four (04) residents or approximately 10 percent of the facility’s population and one (01) staff member. Resident #1 (R1) and Resident #2 (R2) both reported that they did not have privacy during their appointments with the VSO. They stated not verbatim, that meetings were held in a cubicle within arm’s length of another person and that they were not offered the option of a private room. Resident #3 (R3) had not personally met with the VSO but reported hearing complaints from other residents expressing discomfort with the lack of privacy during cubicle meetings. Resident #4 (R4) did not recall meeting with the VSO. R3 added that although they personally did not mind the lack of privacy, they understood why others might be concerned. They did not consider the information discussed to be sensitive but acknowledged that privacy expectations vary among individuals. LPA’s review of the facility’s HIPAA privacy policy found that while staff are required to receive appropriate training, training alone does not replace the need for physical safeguards to protect resident privacy. Based on the information obtained through resident interviews and LPA’s own observations, the allegation that residents are not allowed privacy during VSO appointments is deemed Substantiated at this time. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Copy of report and appeal rights provided.