complaint·September 19, 2025

9099C-1 Allegation: Facility staff are not providing adequate food services. The allegation states resident (R1) was not being fed healthy meals. One staff stated (R1) did not have a special diet but had "no teeth" so was served "soft fruits" along with all the same foods other residents were offered. This staff added (R1) has no dentures currently but bought ribs from the grocery store and asked this staff to prepare them. A second staff stated "sometimes (R1) will eat" and would often gives fruits to (R2), adding (R1) asks for soda, coffee and won't drink water. The physician's report notes (R1) did not have a special diet and the facility confirmed (R1) was served the same food as all other residents and didn't have a problem eating any food, except for hard fruit such as apples. The Administrator stated there is a two week, rotating menu, and (R1) "did not complain to him about meals, but (R1) will say if they don't like something- we always offered (R1) an alternative such as a grilled cheese, chicken/tuna sandwich. An individual who knows (R1) stated (R1) would complain about food served to him when living with their family member and staying at the hospital. All individuals interviewed stated that (R1) would often refuse meals and go outside on the patio and smoke. Resident (R1) stated they were in a "deep depression" when living at the facility and lost 100 pounds in a few months after their daughter passed. The Administrator stated (R1) maintained the same weight and maybe have 5-10 pounds in just 2 months. LPA observed fresh produce on hand and being served with lunch on 8/29/25. LPA interviewed (3) additional residents who indicated the food served is of good quality and variety, and low-salt options are offered. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Facility staff are not providing assistance with ADLs. The allegation states the facility was not allowing (R1) to shower without staff assisting and staff was not monitoring (R1's) blood pressure. Staff stated (R1) would refuse showers, but they were able to ensure (R1) received a shower at least weekly. The Administrator stated staff would ensure (R1) received a shower at least twice weekly. (R1) stated staff helped him several times in the shower; however, he was not comfortable with female staff helping him, and the Administrator explained to (R1) that "he was afraid I would fall". (R1) stated they took a shower with no assistance before and didn't fall, and realizes now the Administrator was "trying to help". *cont 9099C-2.. 9099C-2.. One staff explained that (R1) "keeps insisting that they can do everything themselves" and when Sukh is here, he will try and "encourage (R1) to shower- sometimes (R1) will agree". The Administrator stated (R1) never expressed that they were uncomfortable with female staff giving a shower. An individual who has knows (R1) stated "(R1) would never try and shower when they lived with their family, would wear dirty clothes and this is not new behavior". Additional residents stated care is being provided as needed and staff are very helpful. This portion of the allegation is found to be unfounded. The Administrator stated on 8/29/25 that he just received a verbal blood pressure order 3-4 days ago from (R1) and (R1) has been at the casino the last 2 days". The Administrator stated a doctor's order was never received to take (R1's) blood pressure. The facility provided documentation showing (R1's) blood pressure was taken daily starting on 7/25/25 through 7/29/25 and then daily from 8/1/25 through 8/16/25. Readings varied between low, normal and high. The Administrator decided to document blood pressure readings beginning on 7/25/25 to be able to chart any changes to convey to the doctor. Blood pressure was also taken for other residents on/around end of July 2025 to chart their health status. One staff stated (R1) is hardly at the facility and leaves at 7:00 am, missing breakfast, lunch and dinner. This staff explained that (R1) "just leaves and will not say when they will be back but talks to Sukh" and that (R1) left two days ago and he did not take any medications with him. (R1) stated staff were not checking their blood pressure as much as they were "supposed to", commenting staff had taken it "daily" before, acknowledging the order came later after they went to the Emergency Room in August 2025. The Administrator stated there was never a time when (R1) asked for their blood pressure to be taken and it was not taken by the facility. This portion of the allegation is found to also be unfounded. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. *cont on 9099C-3... . 9099C--3.. Allegation: Facility staff are violating resident's personal rights. The allegation states the facility staff is not allowing (R1) to leave and return to the facility when they choose. Both staff indicated that they have never told (R1) they could not leave the facility by themselves but asked that ( R1) does not if their legs were "shaky" or (R1) was not walking with a steady gait. One staff stated she would call the Administrator who would tell (R1) that they shouldn't go", explaining it takes (3) firemen to pick (R1) up and (R1) fell outside on many occasions. Another individual who knows (R1) stated "if staff see (R1) is in a bad state they may tell (R1) not to go" and commented that the facility has a curfew for a reason. (R1) stated that the Administrator, Sukh, said they couldn't leave if their legs were shaky and realizes now the staff "were doing things for my good- everything was for my own good, and I didn't realize it". (R1) commented "99% was my fault". Three other residents indicated they do not feel their personal rights have been violated in any way. The physician's report (dated 6/2/25), notes (R1) is able to leave the facility by themselves. (R1) received an updated physician's report (dated 9/9/25) notes (R1) is not able to leave the facility unattended. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided.