complaint·July 24, 2025

The Administrator was interviewed. She reported R1 exhibited verbally aggressive behavior toward staff, including raising their voice and denying staff entry into their room. The administrator said staff made routine attempts to offer assistance throughout the day; however, R1 consistently refused services and responded in an uncooperative and hostile manner. Staff were interviewed, where 2 of 2 revealed R1 would be verbally abusive to staff and would not allow staff to assist them with their daily hygiene needs. R1 was interviewed. R1 reported they would request assistance, and staff would refuse to assist. Additionally, R1 denied being verbally abusive toward staff and denied they would refuse assistance with toileting needs and cleaning. Interviews with other residents were conducted, where 4 of 4 residents reported staff assist with toileting and bathing needs when requested and as needed. A record review of facility daily logs was completed. LPA obtained facility records titled “Diaper Log”. This log documents staff assistance with toileting needs. The log is not specific to a resident but instead documents daily assistance. The log was reviewed for January 2025. The log documented R1 refused assistance with toileting a total of 18 times in that month. The log documented R1 accepted assistance with toileting a total of 15 times in that month. LPA obtained facility records titled “Shower Log”. This log documents staff assistance with showering. The log is not specific to a resident but instead documents when showering assistance was provided. The log was reviewed for January 2025. The log did not reflect any refusals by R1. The log documented R1 accepted assistance with showering a total of 3 times in that month. It was alleged residents are forced to eat in the dining room. It was reported that facility staff implemented a policy requiring residents to eat in the dining area or risk not being served meals. It was reported that the policy was announced and implemented in February 2025. The Administrator was interviewed and reported no such policy was implemented . The Administrator stated the facility accommodates residents who are non-ambulatory by delivering meals to their rooms. Staff were interviewed, where it was revealed 3 of 3 staff corroborated the Administrator’s statement, indicating that at no time had there been a policy mandating all residents to eat in the dining area or risk not being provided with a meal. R1 was interviewed and reported, based on the implemented policy, R1 had to come up with alternative meal arrangements. R1 further reported a facility staff informed R1 that meals would not be provided unless consumed in the dining area. Continued on LIC 9099-C . R1 was not able to identify which staff informed them of the policy. Interviews with 4 of 4 staff members stated that they were unaware of, and had not communicated to residents, of a newly mandated policy requiring meals to be consumed in the dining area or risk not being served. Interviews with residents were conducted, where 4 of 4 residents reported they were not told about this policy. Residents reported they have the option to eat in their rooms without fear of being denied meals. Based on record reviews, and interviews with residents and staff, the allegations that facility does not provide assistance with hygiene needs, facility does not respond to resident's request for assistance, and residents are forced to eat in the dining room are deemed Unsubstantiated. A finding of "Unsubstantiated" means that the allegation may have occurred or is valid, there is not sufficient evidence to prove the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided to the Administrator, Ma Satchel Lecita