It is alleged that staff does not accommodate resident’s special dietary needs even though the information is noted in their file due to their health condition. It is also alleged that staff will not allow resident to have hot, vegan-based meals even though they cannot eat meals from the regular menu.

Interviews with (9) out of (9) staff indicated that the facility ensures that residents’ dietary plans are followed. Seven (7) out of (9) staff indicated that they follow meal service guidelines to meet the dietary needs of residents, including those who have special dietary needs. Staff stated that R1’s dietary plan consists of having plan-based items which the kitchen has available. Staff indicated that the facility has an alternative menu which provides hot and cold vegetarian and vegan and plant-based options; however, R1 has not placed orders for those items, yet. Staff stated that R1 has been informed regarding the plan-based options. Staff also indicated that the kitchen makes meal accommodations for residents, including R1 according to their meal preferences if they provide reasonable advance notice to kitchen staff to ensure timely preparation. Furthermore, (3) staff have stated that R1’s Physician Report information regarding R1’s meal modifications have been discussed during in-service training with staff. Interviews with (12) out of (13) residents indicated that the facility provides meals which meet their dietary needs and have no concerns. LPA reviewed the kitchen’s Special Dietary Needs binder and observed that R1’s Physician Report and meal plan is in place. LPA observed the kitchen’s pantry and refrigerators and observed plant-based items readily available. Interviews, observation and record review cound not corroborate the allegation that the facility is not ensuring that resident’s dietary plan is followed.

Regarding: Staff does not ensure resident’s care plan is being followed.

It is alleged that day staff are supposed to check on resident every 2 hours, but instead neglect their care and don't follow their care plan.

Staff deny the allegation. Interviews with (6) out of (6) staff indicated that staff are conducting wellness checks on residents according to their Care Plan. Staff indicated that R1 is checked (4) times per shift by caregivers and staff from other departments as indicated in R1’s Care Plan. Staff indicated that not only are wellness checks conducted in resident rooms, but also in the common areas and any place residents spend time in within the facility. Staff indicated that R1 steps out of their room during meals and other activities and therefore, staff check on R1’s well-being wherever R1 is at the facility, not just in their room. Staff indicated that R1 is sometimes sleeping and is not disturbed by staff during wellness checks and R1 may not notice staff checking in on them. Staff further indicated that they educate R1 on calling on staff in between checks if needed; however, R1 seldom makes calls to staff requesting a visit in between wellness checks***Continues on LIC 9099-C page 2***

Regarding: Facility is not posting the resident council meetings notice for residents to view.

It is alleged that staff are not posting the resident council meeting notices for residents to view.

Staff deny the allegation. Interviews with (4) staff who assist residents with resident council activities indicated that they print and post the monthly meeting notices in the common areas and help distribute them to the residents. Staff indicated that resident council is a resident guided activity; however, facility staff provide help to resident council participants if the help is requested. Staff stated that monthly resident council notices are posted in the main lobby, bistro, activity room, dining rooms, and in the hallways. Staff further stated that as an additional courtesy for residents, staff post the meeting minutes in the bistro and the main lobby bulletin board. Interviews with (4) resident council participants indicated that the facility posts resident council notices about three to four days before the meetings take place, which are conducted on the first Wednesday of every month. Eleven (11) out of (13) residents indicated that staff post the resident council meeting notices around the facility and have observed flyers being passed out in the common areas of the facility. During tours of the facility conducted during the investigation by LPA, the Resident Council Minutes for meetings held on 2/4/2026 at 2:05 p.m. and on 3/4/2026 at 2:02 p.m. were observed on the bulletin board in the lobby by the main entry to the facility. LPA also observed the resident council election result flyers in the lobby’s bulletin board, bistro, hallways by the dining rooms and by the med-tech room. Facility binder with past meeting minutes, meeting notices and other resident council notes was reviewed and observed in the main office.

Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Alisa Dean, and a copy of this report was provided.