complaint·September 4, 2025

Allegation #1: Staff do not ensure that resident is adequately fed The investigation revealed the following: On September 3, 2025, at 10:00 AM , LPA Allen conducted interviews with Staff Members 1 - 9 (S1–S9). All 9 staff members stated that residents are adequately fed daily, including the provision of liquids such as water, juice, and milk. Staff also reported that when a resident refuses to eat after three (3) attempts, a meal replacement is provided. LPA specifically inquired about Resident 1 (R1) and whether R1 was provided dinner on August 23, 2025 . All 9 staff members expressed confidence that dinner was provided to R1; however, none could confirm whether R1 actually consumed the meal. Staff Members 3 and 4 (S3–S4), who have worked directly with R1 but were not on duty on August 23, 2025, during the PM shift, reported that R1 has a history of refusing meals. They stated that after three (3) attempts to encourage eating, a meal replacement such as Ensure is typically offered. At 12:00 PM , LPA interviewed Residents 1- 7 (R1–R7). 6 out of 7 residents confirmed they are provided meals daily, including beverages such as water and juice, and that staff encourage them to drink water throughout the day. LPA attempted to interview R1 on three separate occasions; however, R1 was asle ep each time. At 1:10 PM , LPA reviewed end-of-shift notes from the AM shift dated August 21, 22, 23, 29, and September 2, 2025 . These notes indicated that R1 refused meals on each of those dates. However, a meal replacement was offered, and both the med tech and hospice nurse were informed of R1’s refusal to eat. When LPA requested PM shift notes specifically for dinner on those same dates, the facility was unable to provide them. continued LPA also interviewed Witness 1 (W1) , who reported that R1 was not provided a meal but approximately two hours after dinner was served to other residents typically around 5:00 PM. W1 stated that this appeared to be an isolated oversight, though it was concerning. W1 added that R1 was eventually given a peanut butter and jelly sandwich and tuna salad. On September 4, 2025, at 9:15 AM , LPA attempted another interview with R1. However, R1 was unable to stay on topic or engage in a clear conversation. During this time, LPA observed Staff Member 4 (S4) assisting R1 with eating oatmeal, drinking water, and consuming a bottled Starbucks Vanilla Frappuccino (cold brew). At 12:26 PM , LPA reviewed R1’s file, including physician reports dated April 23, 2025, and July 29, 2025 , as well as the Acacia Hospice of Southern California service plan dated August 5, 2025 . None of these documents indicated that R1 had experienced dehydration or excessive weight loss. Allegation #2: Staff do not ensure that resident is hydrated The investigation revealed the following: On September 3, 2025, at 10:00 AM, LPA Allen interviewed Staff Members 1 through 9 (S1–S9). All staff stated that residents are encouraged to drink water daily and hourly. During the facility tour, staff pointed out water stations available to residents on floors 4, 5, and 6. At 12:00 PM, LPA interviewed Residents 1 through 7 (R1–R7). Six out of seven residents confirmed they are provided meals daily, including beverages such as water and juice, and that staff encourage them to drink water every hour throughout the day. LPA again attempted to interview R1 on three separate occasions, but R1 was asleep each time. Continued On September 4, 2025, at 9:15 AM, LPA made another attempt to interview R1. However, R1 was unable to stay on topic or engage in a coherent conversation. Despite this, LPA observed R1 being assisted by S4 while consuming oatmeal, water, and a bottled Starbucks Vanilla Frappuccino (cold brew). LPA also interviewed Witness 1 (W1), who expressed concerns about R1’s water intake and hydration. However, a review of end-of-shift notes dated August 21, 22, 23, 29, and September 2, 2025 confirmed that R1 was provided water on those dates. Additionally, LPA directly observed R1 drinking water during the visit. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Robert Jakini- Administrator at conclusion of the visit.