Complaint·August 20, 2025

Allegation: Staff did not ensure resident’s dietary needs were met The allegation alleges the facility is serving a resident meat despite knowing they are a vegetarian and admitted knowingly serving them meat. During the facility inspection, LPA observed food that is appropriate for residents with a vegetarian diet. Additionally, LPA observed vegetarian meals available for residents. During record review, LPA received and reviewed Resident R1’s Identification and Emergency Information that states in the Comments R1 is a vegetarian. During review of R1's Physician’s Report dated 04/04/2025 indicates that R1 does not have a special diet. In the Addendum - Personal Rights of the admission packet under Resident Rights, number 7 states residents have the right “To be served food of the quality and in the quantity necessary to meet their nutritional needs.” During interviews with Staff S1-S4, were asked if residents with special diets and preferred diets are accommodated, four (4) out of four (4) stated resident’s special diets and preferred diets are followed. Additionally, during an interview with S1 and S2 stated if a resident does not want what is being served, they will make them something they want to eat. During interviews with Residents R1-R6, were asked if their special diet and/or preferred diets are followed, four (4) out of six (6) stated their special diet and preferred diets are followed. Two (2) out of six (6) stated they do not have a special or preferred diet. Additionally, six (6) out of six (6) residents stated the staff will make them whatever they want to eat if they don’t want what is being served. During an interview with R1, stated staff will ask if they want want is being served, the staff informs them there is meat in the item, and that staff will pick out the meat and they pick out any additional pieces they see. Allegation: Staff threatened resident. The allegation alleges the facility staff threatened to withhold their medication if they did not finish their food. During the facility inspection, LPA observed Resident Rights posted in the facility. During record review, LPA received and reviewed Addendum of the admission packet under Resident Rights number 8 states the resident has the right "To make choices concerning their daily life in the facility." and number 10. that states the resident has the right "To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse." LPA received and reviewed R1's Personal Rights Residential Care Facilities For the Elderly (LIC613C) dated 04/09/2025 that states in number "(3) To be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature, such as withholding of monetary allowances or interfering with daily living functions such as eating or sleeping patterns or elimination." During interviews with Staff S1-S4, were asked if they have or have seen or heard staff threaten a resident to eat something they did not want to, four (4) out of four (4) stated they have not threatened a resident nor have they heard another staff threaten a resident. Additionally, during an interview with Staff S1 and S2, stated they have never threatened a resident to eat their food, but they encourage Resident R1 to eat their food before taking their medication due to the medication needing to be taken with food. During interviews with Residents R1-R6, were asked if staff have threatened to withheld their medication due to not consuming all their food, six (6) out of six (6) stated no, staff have not threatened to withhold their medication due to not eating all their food. Allegation: Staff restricted resident’s visitor(s) The allegation alleges the facility staff restricted a visitor from visiting with a resident for about two (2) months. During the facility inspection, LPA observed the Rights of Residents posted in the facility. LPA reviewed the visitor sign-in logs at the entrance and observed Resident R1 has had multiple visits while residing in the facility. During record review, LPA received and reviewed the Admission Agreement for Resident R1, dated 04/09/2025, that states on page 5 “Visiting hours are from 10AM to 5PM.” In the Addendum of the Admission Agreement lists Resident Right that states in number 24. the resident has the right “To consent to have relatives and other individuals of the resident's choosing visit during reasonable hours, privately and without prior notice. Additionally, in the admission packet, is the Personal Rights Residential Care Facilities For the Elderly (LIC613C) dated 04/09/2025, states in number (11) To have his/her visitor, including ombudspersons and advocacy representatives permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. During interviews with Staff S1-S4, were asked if they have restricted a resident’s visitations with friends and family, four (4) out of four (4) stated they have not limited a resident’s visitations with friends or family. Additionally, during an interview with S1 stated they were asked by a resident’s family to deny visitation of a resident’s friend and they informed the family they may not restrict a residents visitation rights. During interviews with Residents R1-R6, were asked if the staff have restricted their visitations with friends and family at any time, six (6) out of six (6) stated staff have not restricted their visitation. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . An exit interview was conducted with Caregiver, Freddie Brown, and a copy of this report was provided.