complaint·July 7, 2025

Allegation: Staff are not providing adequate food service for resident. The complaint alleges residents in the memory care unit are not provided adequate snacks because staff are not always providing snacks to residents, and resident (R1's) authorized representative was asked to buy snacks for the resident. Resident interviews revealed that in January 2025- February 2025 drinks were available in the 1st floor lobby area and/or kitchen. On 2/6/2025, during the physical plant inspection after lunch meal the kitchen, common areas, and Memory Care Unit cabinets and refrigerator, it was observed that the 1st floor lobby area only offered drinks to residents, and the Memory Care Unit refrigerator did not have an adequate supply of snacks in the refrigerator. Staff stated they have never asked R1's authorized representative to pay for snacks. However, staff interviews revealed that the memory care unit did not at that time have on hand snacks for residents every day, and only some staff took initiative to request snacks from kitchen staff if needed. Staff stated that when family request specific snacks that are not typically provided by the facility they are encouraged to bring those snacks to the facility. Staff also stated that snacks should be provided in between regular meal times. Per Admission Agreement, the facility "will serve three (3) nutritionally balanced meals and snacks daily to residents at La Posada." Based on observations and picture evidence, there is sufficient evidence to support the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Beatriz Rome Lui. A copy of the report and appeal rights were provided. Allegation: Staff are retaliating against resident's authorized representative. The complaint alleges that staff told resident (R1's) authorized representative that transfer/move in arrangements and belongings pick-up from another RCFE would be taken care of by the facility. According to information obtained, Administrator was unprofessional and argued with authorized representative about move-in transfer issues, instructions on hospital bed pick-up and hospice enrollment. It is alleged that Administration staff are retaliating by ending hospice services for R1. A total of nine (9) staff were interviewed. Based on interviews conducted the findings indicate that resident (R1) moved in on December 20, 2024 with active hospice enrollment, but on February 5, 2025 hospice agency terminated services due to "family no longer wishes to receive hospice services." On 2/5/2025, Administration staff notified authorized representative of change. Per record review, the findings indicate that the facility made numerous telephonic and email attempts to speak to R1's authorized representative about care plan, hospice enrollment, and admission agreement, but did not receive a response to meeting requests. Resident (R1's) file was reviewed, it revealed the facility made multiple attempts via telephone calls, texts, emails, and scheduled meetings to communicate with authorized representative regarding representative concerns. However, R1's authorized representative cancelled meetings and/or did not reply to emails and telephone calls. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not have resident or authorized representative sign an admissions agreement upon admission. It is alleged that resident (R1's) authorized representative did not sign an admission agreement when the resident moved in and was emailed an admissions agreement until January 30, 2025. Staff interviews revealed that resident (R1's) authorized representative electronically signed the admission agreement on December 15, 2024, with the exception of page 18. According to interviews and file review, there were multiple attempts made by former Administrator and administration staff to address the missing admission agreement signature. Staff interviews revealed there were multiple meetings scheduled with R1's authorized representative to obtain the missing signature, but the authorized representative denied signing the admission agreement electronically, and accused staff of forging their signature. Executive Director stated the resident moved out on June 4, 2025, and the authorized representative never signed the missing signature on page 18 of the admission agreement. Based on file review conducted today, Dropbox Sign records indicate that the admission agreement was sent electronically to R1's authorized representative on 12/13/2024, and the admission agreement was signed and completed on 12/15/2024. None of the residents interviews supported the allegation. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: Staff are not treating resident equally. The complaint alleges that memory care resident (R1) is not being treated equally during snack time because if the resident is in their room staff do not give the resident a snack, since residents have to be in the common activity room to receive a snack. Staff interviews revealed that residents in the Memory Care Unit and Assisted Living floors are provided snacks every day. For instance, in the memory care unit staff pass out snacks in the common area room, and if a resident is in their room they are offered snacks or encouraged to pick them up in the common area activity room. Staff stated residents are provided bananas, juice, water, and coffee. According to staff, R1 constantly repeated to staff that they were hungry even after they finished eating their regular meal. Resident (R1) did not require a special diet. When resident (R1) was interviewed they stated staff did not give them snacks, but the resident was not oriented to time or place. Resident interviews revealed all residents are offered snacks in between meals. None of the residents stated they are not treated equally. There is insufficient evidence to support the allegation. Allegation: Staff are not following resident's authorized representative's directives about visitors. It is alleged the facility keeps allowing resident (R1's) other family member to visit the resident despite the authorized representative's directive to restrict the family member from visiting the resident. Staff interviews revealed residents are asked by staff if they would like to see a visitor that arrives at the facility. Resident (R1) resides in the memory care unit and the resident agreed to the family member's visits. Additionally, Administration staff stated the authorized representative did not present a restraining order against the family member they wanted restricted. Based on file review, LPA confirmed there is no restraining order in place. Therefore, staff did not prohibit any family and/or visitors from seeing resident (R1). None of the residents interviewed supported the allegation. There is insufficient evidence to corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to facility Executive Director Beatriz Romeo Lui.