complaint·December 1, 2025

R1 stated they receive meal delivery and expect meals to be brought to the room daily. R1 also told LPA that they purposely did not press their call button that day to “prove a point,” believing staff should notice when they have not eaten. R1 stated meal delivery usually takes 45 minutes to an hour. R1 reported that staff have told them they sometimes avoid entering the room if R1 is sleeping because R1 becomes upset when awakened. R1 also stated that earlier in the year, workers were in their room fixing bathroom plumbing. R1 said workers walked in and out without concern for privacy and that R1 was never offered a temporary room. R1 stated the bathroom repairs lasted 21 days. R1’s bathing schedule is Thursday and Sunday. R1 stated they did not receive three Sunday baths in a row but did receive their Thursday baths. LPA interviewed several other residents on July 29,2025 and December 1, 2025. Residents interviewed reside on the same floor as R1. All residents reported no issues with food service, privacy, or care. LPA interviewed Staff 1 (S1) on December 1, 2025. S1 stated that R1 is very particular about how things should be done. S1 said R1’s mood can vary, especially after returning from medical visits. S1 confirmed R1 is scheduled for two baths per week and stated that if a bath is missed, it is usually because R1 refused. S1 explained that staff go to R1’s room when R1 calls but avoid unannounced entry because R1 becomes upset. LPA interviewed Staff 2 (S2) on December 1, 2025. S2 stated R1 likes tasks done in specific ways and becomes frustrated when they are not done exactly as requested. S2 confirmed R1’s bathing schedule. S2 stated that if R1 dislikes a certain staff member, R1 refuses a bath from that person, and staff must rearrange schedules to accommodate this. S2 recalled workers being in R1’s bathroom months ago but stated the work lasted only one or two days, not several weeks. S2 said staff only enter R1’s room if called because R1 becomes upset when staff enter without notice. Regarding food service, S2 said they deliver meals to multiple residents and delays may occur because they are also assisting with care tasks. S2 said they do not believe R1 ever missed a meal because one time when the kitchen did not receive R1’s order, R1 insisted S2 retrieve the meal immediately, and S2 did so. Manager of Maintenance (MM) stated R1 was offered a guest room during the bathroom repair period, but R1 refused the offer. MM stated R1 told them they do not use the bathroom at all. MM stated outside vendors were escorted and did not have a way to enter R1’s room freely. The bathroom had only one access point, and workers had to pass the pony wall to reach the repair area. A nearby light fixture was removed and later reinstalled after patching and painting. On December 1, 2025 the Director of Heath Services (DHS) stated that R1 does not receive wellness checks as part of their service plan. Staff check on R1 only during scheduled services or when R1 requests assistance. R1 has showers scheduled twice each week, but the schedule sometimes changes when R1 refuses a shower or prefers to wait for specific staff to return to work. LPA reviewed meal delivery procedures and logs. Records showed: Residents who want room delivery fill out a room-service meal form. Residents on regular delivery can fill out a form each time or have a standing order. For residents requiring escort service (including R1):A room service order form is completed by the resident, nursing staff, or by standing order. The meals-to-go server prepares the meal. Meals are placed on the bistro counter. Nursing staff pick up the meal, sign the delivery slip, and deliver it. Scheduled meal times are: Breakfast: 8:45 a.m. Lunch: 11:45 a.m. Dinner: 4:45 p.m. Based on the documented meal times and meal delivery process, R1’s reported 45-minute to one hour wait time falls within the documented delivery window. In regards to Bathing Needs: R1 reported missed Sunday baths, but staff and records showed baths were offered, and refusals and scheduling adjustments were involved. In regards to Food Service: R1 stated they missed meals but also reported they purposely did not call for help. Meal procedures and records show R1 was provided meals within the expected time frame. In regards to R1 being left attended: No evidence showed R1 was ignored. Staff check in during scheduled services or when R1 calls. In regards to R1's privacy rights being violated. No evidence showed that anyone violated R1’s privacy, and maintenance staff reported workers were escorted and did not have direct access to R1’s room. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are unsubstantiated. An exit interview was conducted with Corinna Norton. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Corinna Norton whose signature below verifies receipt of these rights.