Complaint·September 23, 2025

Allegation – staff are verbally and physically abusing residents: During the investigation, LPA reviewed the facility’s records, including staff training documents, resident care plans, and incident reports. LPA interviewed residents, staff members, and facility management. Resident interviews did not confirm any instances of verbal or physical abuse. Most residents mentioned that staff were kind and respectful, and they had not observed or experienced any form of abuse from staff. Staff members also stated that they were trained to handle residents with care and follow proper procedures when assisting them. Staff also mentioned that they have one resident who can never be satisfied, despite providing everything they asked for. Furthermore, there were no documented incidents of abuse in the facility’s records and there were no reports that matched the allegations of verbal or physical abuse. After gathering all available information, there is insufficient evidence to support the claim that staff members were verbally or physically abusing residents. Based on the interviews, records, and observations, the allegation of verbal and physical abuse is unsubstantiated . *************************************************************************************** Allegation – staff leave residents on floor for an extended period of time: As part of the investigation, residents currently living at the facility were interviewed. Residents stated that they receive help from staff when they ask for it. None of the residents confirmed that staff leave them on the floor or ignore them when they need assistance. Residents shared that staff respond to their needs and treat them with care and respect. Facility staff were also interviewed. Staff denied any form of abuse or neglect happening in the facility. One staff member stated that they always provide residents with what they ask for and make sure their needs are met in a timely way. In addition to the interviews, LPA reviewed copies of residents’ admission agreements. Under the “Personal Services” section, the agreement outlines that the facility will provide continuous care and supervision, monitor changes in condition, assist with medical and dental needs, and provide bedside care when needed for minor illness or recovery. Facility records and staff interviews confirmed that there is staff on duty during the night shift, from 7pm to 7am, to provide care and supervision to residents during the night. {pg.2} Based on the information gathered during interviews and document review, there is not enough evidence to support the claim that staff leave residents on the floor for extended periods of time. Therefore, the allegation is unsubstantiated . ***************************************************************************************** Allegation – staff do not ensure residents are provided quality food: As part of the investigation, residents were interviewed. Residents stated that they receive enough food and did not express concerns about the quality of meals. None of the residents confirmed the allegation that food being served is not good or not provided. Interviews with staff also did not confirm the allegation. Staff members explained that food is always given to residents and that staff provide what residents ask for. Staff reported that meals are prepared daily and follow a regular meal schedule. LPA reviewed the facility’s menu, which is structured on a 2-week rotating schedule. The menu includes a variety of meals for breakfast, lunch, and dinner, and offers different types of proteins (such as sausage, chicken, turkey, ham, and fish), starches (like rice, potatoes, macaroni, waffles, and pancakes), as well as vegetables and fruits. The meals appear to be balanced and follow appropriate food groups. Fruits are mostly served with breakfast and lunch, and many dinners include a protein, a starch, and a vegetable. LPA also reviewed the residents’ signed admission agreements. Under the “Food Services” section, the agreement states that residents will be provided with three nutritious meals and three snacks each day. It also mentions that special diets will be provided if ordered by a doctor. Lastly, during site visits on 5/8/25 and 6/18/25, LPAs Arvin Villanueva and Sommer Hayes observed the facility’s kitchen, refrigerators, freezers, and pantry. There was an adequate supply of food, including at least two days’ worth of perishable food and seven days’ worth of non-perishable food. A variety of items were present, such as fresh and frozen meats, vegetables, fruits, and canned goods. Based on interviews, document review, and observations, there is not enough evidence to support the claim that staff fail to provide residents with quality food. Therefore, the allegation is unsubstantiated . Note that a finding that is unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Based on today’s visit, no deficiencies were cited. Exit interview was conducted with S3 and a copy of this report and appeal rights were provided. {pg.3}