Complaint·July 23, 2025

The investigation revealed the following: Allegation: Staff do not provide adequate food service. It is being alleged that a resident in care is not receiving good nourishment at the facility. On 7/10/25 from 10:14 am-10:45 am LPA conducted Interviews with S1-S2 regarding the allegation above, 2 of 2 staff denied the allegation. Per 2 of the 2 staff interviewed, residents in care obtain 3 meals a day with snacks in between, residents are provided with additional food servings upon request. Additionally, staff have observed that R1 has been hesitant to accept nourishment, expressing feelings of mistrust and concerns about potential harm. On 7/10/25 from 11:30 am-12:04 pm interviews were conducted with resident #1-3 (R1-R3), 2 of 3 residents interviewed denied the allegation above, and did not report any concerns about the food being provided. 1 of 3 residents interviewed acknowledged the concerns raised and mentioned that the quality of the meals does not seem to meet expectations, implying that some of the items may not be as authentic as expected initially. On 7/10/25 LPA was unable to interview R4-R6 due to communication barriers. On 7/10/25 LPA conducted telephone interviews with W1-W3 regarding the allegations above, 3 of 3 witnesses interviews reported having no concerns about the food being provided at the facility. On 7/10/25 at 10:45 am LPA conducted tour of the facility, LPA observed the facility kitchen to have 2 refrigerators: 1 stores protein, 1 stores vegetables, milk, and juice. There is 1 pantry filled with canned goods, there was also fresh fruit observed. On 7/16/25 LPA conducted a review of staff notes dated 6/26/25, LPA documented that R1 has indicated a reluctance to accept nourishment. Allegation: Staff do not ensure resident in care has access to a bathroom. It is being alleged that facility staff are denying R1 access to the bathroom. On 7/10/25 from 10:14 am-10:45 am LPA conducted Interviews with S1-S2 regarding the allegation above, 2 of 2 staff denied the allegation. Per 2 of the 2 staff interviewed, there is only 1 resident in care that uses the bathroom independently and reports that resident has not been denied access to the bathroom. Additionally, staff members have indicated that a plumber has been requested to visit the facility several times each week to address ongoing issues with toilet drainage. On 7/10/25 from 11:30 am-12:04 pm interviews were conducted with resident #1-3 (R1-R3), 2 of 3 residents interviewed denied the allegation above, and reported that staff assist with incontinent needs. 1 of the 3 residents interviewed acknowledged the concern raised and mentioned experiencing difficulty accessing the bathroom, with staff citing hygiene issues as the reason for this restriction. On 7/10/25 LPA was unable to interview R4-R6 due to communication barriers. On 7/10/25 LPA conducted telephone interviews with W1-W3 regarding the allegations above, 3 of 3 witnesses interviewed reported having no concerns about toileting needs being met. On 7/22/25 LPA conducted a review of R1’s physicians report, per physician’s report R1 is able to care for R1’s toileting needs. Allegation: Staff do not safeguard resident's' personal property It is being alleged that facility staff have taken R1's shoes and clothes. On 7/10/25 from 10:14 am-10:45 am LPA conducted Interviews with S1-S2 regarding the allegation above, 2 of 2 staff denied the allegation. Per 2 of the 2 staff interviewed, R1 does not allow staff near R1 belongings and R1 refused to sign an inventory log upon admission. Per staff, R1 has reported items missing that were later found under R1’s bed. On 7/10/25 from 11:30 am- 12:04pm interviews were conducted with resident #1-3 (R1-R3), 2 of 3 residents interviewed denied the allegation above. 1 of the 3 residents interviewed confirmed the allegation above, per resident the facility staff allow people into the facility therefore the staff is responsible for items going missing. On 7/10/25 LPA was unable to interview R4-R6 due to communication barriers. On 7/10/25 LPA conducted telephone interviews with W1-W3 regarding the allegations above, 3 of 3 witnesses interviewed reported having no concerns about the allegation above. On 7/16/25 LPA conducted a review of inventory logs dated 6/5/25, per log R1 refused to complete the inventory log upon admission. On 7/16/25 LPA conducted a review of staff notes dated 6/26/25, per staff notes R1 accused staff of stealing belongings, R1 does not want staff to touch or arrange belongings, shoes reported stolen were under R1’s bed. On 7/22/25, LPA reviewed R1's physician's report and Preplacement appraisal. It was noted in the preplacement appraisal that R1 is facing challenging behaviors related to major neuro cognitive disorders (NCD). Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, and a copy of this report was provided.