complaint·September 9, 2025

Face Sheet with updated service plan dated 7/29/2025, Physician’s Report dated 12/5/2023 and 4/23/2025. End of shift reports dated for the following dates 8/21/2025, 8/22/2025,8/23/2025, 8/29/2025 and 9/2/2025 for the AM shift. Acacia Hospice of Southern California service plan dated 8/5/2025. LPA also obtained the staff shift schedule for 8/23/2025 and LPA conducted interviews with Staff Members 1-9 (S1-S9), Residents 1-7 (R1-R7) and Witness 1 (W1). 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) and 9 out of 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 and documented on end of shift notes. LPA specifically inquired about Resident 1 (R1) and whether R1 was provided dinner on August 23, 2025, and 9 out of 9 staff members expressed confidence that dinner was provided to R1; however, none could confirm whether R1 consumed the meal. At 12:00 PM, LPA interviewed Residents 1 - 7 (R1–R7) and 6 out of 7 residents reported that they are provided meals daily, including beverages such as water and juice, and staff encourages them to drink water throughout the day. LPA attempted to interview R1 on three separate occasions; however, R1 was asleep each time. During the visit, LPA observed a clear cup of water with a straw on R1’s bedside, along with a green thermos that appeared to be full when picked up and in reach of the residents’ bed. 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). Continued LPA interviewed Witness 1 (W1), who stated Resident 1 (R1) was not provided a meal until approximately two hours after dinner was served to other residents, which typically occurs around 5:00–5:30 PM. When asked if R1 eventually received a meal, W1 confirmed yes, a peanut butter and jelly sandwich and some tuna which R1 wouldn’t eat and was given an ensure meal replacement. 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, weight loss or a special diet. LPA reviewed the end of shift reports dated 8/21/2025, 8/22/2025, 8/23/2025, 8/29/2025 and 9/2/2025 for the AM shift which does reflect that R1 had refused their breakfast and lunch but R1 was given and willing to drink a meal replacement (Ensure) and water along with notifying Medtech of missed meals. When LPA requested PM end of shift notes specifically for dinner on those same dates, the facility was unable to provide them. 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- 9 (S1–S9) and 9 out of 9 staff stated that residents are encouraged to drink water daily and reminded hourly. During the facility tour, staff pointed out water stations available to residents on floors 4, 5, and 6 and LPA observed residents drinking water. At 12:00 PM, LPA interviewed Residents 1 - 7 (R1–R7) and 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. On 9/3/2025, LPA attempted to interview R1 on three separate occasions, During the visit, LPA observed a clear cup of water with a straw on R1’s bedside, along with a green thermos that appeared to be full when picked up and in reach for the resident’s bed. Continued 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). 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, reflects that R1 was provided with water and Ensure meal replacements on those dates. Additionally, LPA directly observed R1 drinking water and eating during the visit. 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, weight loss or a special diet. 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 violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Nikki Tang- Medtech at conclusion of the visit.