complaint·December 11, 2025

Regarding the allegation, “Staff did not ensure resident received meals,” it is being alleged that Resident #1 (R1) meals were delayed or missed in August 2025. Record review of R1’s August 2025 ledger revealed tray services charges from 08/01/25 – 08/08/25. Three out of three staff interviews (S2 – S4) indicated that the care staff monitor that resident receive their meals. Interview with the Executive Chef (S6) indicated that R1 has not made any complaints. Staff #7 indicated R1 has not had tray service complaints and has meals downstairs. S2 indicated R1 received tray services a couple of times due to illness but usually eats downstairs by the second day. R1 has also complained about it not arriving on time but tray services are delivered to the first, second, fifth, and sixth floors respectively. R1 indicated that R1 eats downstairs but has received tray services. R1 indicated that the food quality for tray services was not very good. Five out of five residents indicated (R8 – R12) that eats downstairs. Resident #2 indicated that tray services were received on time. Regarding the allegation, “Staff did not ensure resident received meals,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Regarding the allegation, “Staff did not ensure resident was getting showers,” it is being alleged Resident #1 (R1) did not receive showers according to the plan of care in August 2025 and between 10/22/25 – 10/23/25. It is alleged that R1 is on an every-other-day shower schedule. Record review of R1’s Resident Assessment (06/12/25) revealed R1 requires total assistance for all showering/bathing needs 4x/week. Record review of R1’s Resident Assessment (10/31/25) revealed R1 requires total assistance for all showering/bathing needs 1-2x/week. Four out of four staff interviews (S4 - S7) indicated there has not been any shower complaints. S2 indicated that R1’s showers increased from twice per week to four times per week (Sunday, Tuesday, Thursday, and Friday). Executive Director indicated that R1 is receiving four showers at the standard rate (two showers). R1 indicated that showers are given according to the agreement; however, there were issues in the past because staff did not want to give showers to R1. R1 indicated that things got better. Two out of two residents indicated (R2, R11) that showers are given according to agreement. R8 – R10, R12 are independent. Regarding the allegation, “Staff did not ensure resident was getting showers,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Continue to LIC9099-C. 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, as a result, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to Dina Davis.