complaint·September 8, 2025

Regarding: Resident was not accorded privacy while in care. It is alleged that staff enter a resident’s room during the night without consent, making it difficult to sleep. Interviews with (6) out of (6) staff deny the allegation. Interviews with staff indicated that staff have to enter rooms to conduct health checks on all residents, particularly those who need assistance with (ADLs) which include doing checks on residents during the night shift. Staff stated that before entering residents’ rooms, they must knock, announce themselves and wait for permission from residents to enter their rooms. Interviews with staff further indicated, staff are respectful of residents’ privacy and will only visit rooms if residents allow staff to enter or if there is a medical emergency and staff need to have access to residents in distress. Interviews with (9) out of (10) residents indicated they are accorded with privacy, and they do not have any concerns. Residents further indicated that staff are respectful when visiting their rooms and understand that staff have to enter their rooms to help meet their needs. Interview with R1 indicated that staff were entering their room during the night shift without R1 requesting staff to come to their side; however, staff are now visiting their room, once before bedtime to get help with personal hygiene and then in the morning to help R1 prepare for their day. Staff and resident interviews do not corroborate the allegation. Regarding: Staff yelled at resident. It is alleged that staff are verbally aggressive and that staff yell at a resident. Interviews with (9) out of (9) deny the allegation. Staff interviews revealed that staff are not verbally aggressive toward residents nor yell at them. Staff also indicated that they have not heard other staff yell at residents. Staff stated they are respectful and use a soft tone of voice when speaking to residents. Interviews with (9) out of (10) residents indicated, staff do not use verbal aggression nor yell at them. Residents indicated, staff are friendly and respectful when talking to residents. Residents further stated staff interactions are appropriate, and they have no concerns. Interview with R1 indicated, staff sometimes do not talk to them calmly and use loud tones of voice when speaking to them; however, the situation has become better, and staff are using more appropriate tones to talk to R1. Staff and resident interviews do not corroborate the allegation. Regarding: Staff did not administer resident's medication in a timely manner. It is alleged that staff are not checking a resident’s vitals nor providing resident with their medication in a timely manner. Staff deny the allegation. Interviews with (6) out of (6) staff indicated, R1has been provided with their medication in a timely manner. Staff indicated that R1 receives all their medication as prescribed by their doctor, and medication is administered on time and documented accordingly. However, R1 has been requesting Acetaminophen 500 mg. tablets (PRN) in between the doctor prescribed doses which are to be given to R1 for pain every six hours. Staff have informed R1, they cannot receive “extra” doses of the Acetaminophen tablets outside of the doctor ordered doses which are given to R1 every six hours for recurring pain. Staff have explained to R1 that over-medication can be harmful to their health and therefore, physician’s orders have to be followed. Staff also indicated, vitals are taken of residents if there is a physician’s order in place or if resident is experiencing a medical emergency. Staff further stated, R1 does not have an order by their physician to have their vitals checked; however, if R1 complains about having a medical emergency, staff will proceed with taking vitals and getting the appropriate medical attention for R1. Record review/eMAR for R1 indicated, R1 is receiving their daily doses of Acetaminophen 500 mg. tablets (PRN) as prescribed by their doctor. Record review for R1 also indicated, R1 does not have an order from their physician for staff to check their vital signs in R1’s facility record. Interview with R1 indicated, they request “extra” Acetaminophen tablets from staff because they want to take it before the recurring pain in her knee and sometimes headaches set in. Interviews with (9) out of (10) residents indicated they have no concerns with receiving their medication in a timely manner. Staff and resident interviews and record review do not corroborate the allegation. Regarding: Facility is not meeting resident's dietary needs. It is alleged that resident is having difficulty eating the food served in the facility. Interviews with (6) out of (6) staff deny the allegation. Interviews with staff indicated, when providing meals to R1, they have to follow the mechanical diet specifications so that R1 can eat their meals conformably. Specifications indicate, R1’s food has to be soft and chopped which is ordered by R1’s doctor. Staff indicated, all kitchen staff follow the dietary needs of all residents who need modifications when preparing their food. ***Continues on LIC 9099-C page 2 When residents want something other than what is on the menu, they can choose something from the alternative menu which will also be modified to meet their dietary needs. Staff further stated, resident allergies, intolerances and type of modifications needed are posted in the kitchen and updated accordingly. Interviews with (9) out of (10) residents stated, facility provides them with adequately prepared food for their dietary needs and have no concerns. Interview with R1 indicated, facility’s kitchen does not prepare their food to their liking and stated that they give R1 the same food every day. LPA observation of R1’s meal services (breakfast and lunch) indicated, items on R1’s plates were observed chopped and served according to physician orders. Review of the facility’s menu indicated there is proper variation of food items throughout the month. Review of R1’s records indicate, resident is to be provided with a mechanical soft diet which should consist of soft, chopped food items. Further record review indicated, kitchen has updated list of resident dietary needs which is referred to when preparing resident meals. Staff and resident interviews, LPA observations and record review do not corroborate the allegation. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report was provided.