complaint·December 5, 2025

The investigation revealed the following: regarding the allegation “Staff are retaliating against resident.” It is alleged that staff are retaliating against a resident. Eight (8) out of the nine (9) residents interviewed did not corroborate this allegation. Interviews with eight (8) residents revealed that staff have never retaliated against them and have always been professional when providing care. Six (6) out of the six (6) staff interviewed denied this allegation. Staff interviewed revealed that any type of mistreatment or retaliation against residents is not allowed and would report retaliation if they observed it. Review of S4-S6 personnel files did not corroborate the allegation that staff are retaliating against a resident. 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, therefore the allegation is UNSUBSTANTIATED. “Staff are not ensuring that resident is provided meals in a timely manner.” It is alleged that staff are not ensuring that a resident is provided with meals in a timely manner. Eight (8) out of the nine (9) residents interviewed did not corroborate this allegation. R5 and R6 revealed they have received their meals late in the past, but it was within reason, and they felt that their meals were late due to their table placement. Six (6) out of the six (6) staff interviewed denied this allegation. Staff interviews revealed that the dining room is set up as a “restaurant” style dining experience and residents’ orders are taken by servers once the resident is seated. Staff interviews revealed that once a server takes a table’s order, servers place the tickets on holder in the kitchen for the cooks but sometimes the kitchen gets backed up by plating the orders or if a resident changes their mind and orders something different, the ticket gets placed in order received. On 11/10/25, LPA Ramirez observed servers taking lunch orders and bringing meals out to resident tables. LPA Ramirez observed most meals were delivered to tables within 4 to 6 minutes of orders being placed. 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, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for this complaint investigation. A copy of this report was provided via email due to printer out of ink.