Complaint·September 17, 2025

Continued LIC9099-C, page 2 Investigation revealed the following: Allegation: Staff do not ensure the residents' dietary care plan is being followed. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. Five out of five (5 out of 5) staff members and nine out of ten (9 out of 10) residents stated that staff ensure residents' dietary care plans are being followed. They confirmed that staff consistently adhere to physician-prescribed dietary menus and that residents are served well-balanced, nutritious meals according to the doctors' orders. 5 out of 5 staff members and 9 out of 10 residents also stated that the facility does have a dietitian. R1 reported that staff do not ensure the residents' dietary care plans are being followed. LPA requested R1's physicians' report and reviewed the resident's special diet documentation. 5 out of 5 staff members confirmed that R1 is on a diabetic diet, and R1's physician's report, dated 05/28/2024, also indicated that R1 is on a diabetic diet. LPA observed both the facility's regular menu as well as the diabetic alternative menu available for residents on a special diet. Staff stated that according to the residents' physicians' orders, they will accommodate special diets, including low sugar, carbohydrate, mechanical soft, and pureed options. S1-S5 and R2-R10 all denied the allegation. Allegation: Staff do not ensure the resident is provided with breakfast, lunch, and dinner each day. On 04/28/2025, the Department interviewed staff members #1-#5 (S1-S5) and residents #1-#10 (R1-R10) regarding the allegation. All five staff members (5 out of 5) and nine out of ten residents (9 out of 10) stated that staff ensure the residents are provided with breakfast, lunch, dinner, and snacks. Residents (9 out of 10) confirmed they receive three meals per day, and alternative food choices are offered. The facility provides a diverse range of food options, and if a resident requests a second serving, staff accommodate the request. Residents #2-#10 (R2-R10) stated they receive plenty of food to eat, and if they don't want to dine in the dining lounge, they can complete a tray service request. Staff will collect the request slip and deliver the meal to the resident's room. R1 stated that staff do not ensure residents are provided with breakfast, lunch, and dinner each day. LPA observed residents eating lunch and dinner and reviewed the food menus. LPA also observed an ample supply of perishable and non-perishable food items, as well as staff serving meals during breakfast and lunch. Additionally, LPA reviewed the resident's tray service form. S1-S5 and R2-R10 all denied the allegation. Staff members #1-#5 (S1–S5) and residents #2-#10 (R2–R10) all denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation: Staff do not ensure adequate care and supervision are provided to residents On 04/28/2025, between 10:00 a.m. and 11:30 a.m., the Department interviewed five (5) staff members identified as Staff #1 through #5 (S1-S5), regarding the allegation that staff do not ensure adequate care and supervision is provided to residents. The concern involved an incident in which a resident allegedly entered Resident #1's (R1) room without permission while R1 was sleeping. Staff #1, #3, #4, and #5 (4 out of 5) staff members stated they had no knowledge of any resident entering R1's room without permission while R1 was sleeping, and that this matter was never brought to their attention. S #2 stated that R1 reported another resident had entered their room; however, there were no witnesses to the incident, and a review of the facility’s surveillance cameras dated 04/20/2025 did not reveal any unauthorized entry. S2 also stated maintenance checked R1's door and confirmed it was in operable condition. All five staff members (5 out of 5) stated that adequate care and supervision are provided to all residents. 5 out of 5 staff members explained that care staff conduct wellness checks on residents every two hours. 5 out of 5 staff members stated that residents have pendants and call buttons to alert staff if they need assistance. 5 out of 5 staff members confirmed that no unauthorized individuals were observed entering residents’ rooms. 5 out of 5 staff members stated residents’ doors remain locked, and each resident has a personal key to their own room. S1-S5 reported that the facility currently has about 93 staff members employed and is fully staffed, and that residents are receiving appropriate care, supervision, and assistance with their daily needs. All five staff members interviewed (5 out of 5) confirmed the facility is sufficiently staffed and denied the allegation. On 04/28/2025, the Department observed R1's room and confirmed the doorknob was in operable condition; once locked, the door required a key to be unlocked. The surveillance footage dated April 20, 2025, did not show a resident entering Resident #1's room at night. See continued LIC9099-C page 4 Continued LIC9099-C page 4 On April 28, 2025, between 11:45 a.m. and 12:00 p.m., the Department reviewed the facility’s Personnel Report (LIC 500), which listed the following staff positions: Executive Director; Human Services Director; Vice President of Operations; Business Office Manager; Human Resources Director; Resident Care Director; ALW Coordinator; 4 Licensed Vocational Nurses (LVNs); 2 Community Liaisons; 2 Maintenance Staff; 4 Cooks; 5 Kitchen Staff; 4 Food Servers; 2 Dishwashers; 6 Dietary Aides; 9 Medication Technicians; 7 Memory Care Caregivers; 1 Memory Care Activity Director; 2 Activities Assistants; 25 Caregivers; 7 Housekeepers; 4 Receptionists; and 1 Driver a total number of employees listed: 93, confirmed the facility is adequately staffed. On April 20, 2025, there were 10 staff members on the night shift at 9:30 p.m. No incident reports were filed regarding the allegation. None of the caregivers reported witnessing anything, and nothing was documented or found in the residents' records. On April 28, 2025, between 12:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with ten residents #1-#10 (R1–R10) regarding the allegation of inadequate care and supervision. 9 out of 10 residents stated that the facility is adequately staffed and confirmed they are receiving the necessary care and supervision. 9 out of 10 also states that staff are consistently present every shift. 1 out of 10 residents expressed concern about staffing and did not feel care and supervision were adequate. Nine out of ten (9 out of 10) residents reported that they were happy living at the facility and had no problems or complaints. The majority of residents (9 out of 10) denied the allegation and stated that their daily needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegations. 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 deemed unsubstantiated. LPA Bunker provided Executive Director Brittney Buchannan with copies of the LIC9099 and LIC9099Cs Complaint Investigation Reports. There were no deficiencies cited. An exit interview was conducted.