complaint·June 19, 2025

Page 2 Allegation: Residents are not being showered timely. All 5 staff interviewed stated the residents are showered 2 or 3x per week depending on the resident’s Care Plan. If resident refused, they endorse and report to their supervisor and med-tech and the next shift care staff will try to provide shower. During investigation, LPA observed the residents were clean. Due to medical diagnosis, LPA was not able to obtain information from the 2 residents. Therefore, the allegation is closed as unsubstantiated. Allegation: Residents are not being changed timely. All the 5 staff interviewed stated residents are changed 2 to 3x times during their shift and as needed. PED stated there are some residents who still can go to the bathroom but residents are checked every 2 hours and diapers are changed as needed. LPA didn’t observe resident with urine odor. Due to medical diagnosis, LPA was not able to obtain information from the 2 residents. Therefore, the allegation is closed as unsubstantiated. Allegation: Residents needs are not being met due to a lack of staffing Reporting party (RP) stated that the laundry was not being done. RP also stated the activity director is cooking, because the cook quit and sometimes care staff were pulled to cook. All the 5 staff interviewed stated they were never pulled from the floor to cook. When the cook quit, S1 came on board to do the cooking. LPA interviewed S1 who confirmed he was the pro tem cook at that time. ........continued on 9099C (page 3) Page 3 The 5 staff including the PED stated the residents never run out of clean clothing. The PED also stated the facility has 2 washers and it never happened that both are broken at the same time. When one is broken, it gets fixed right away. Two of the 5 staff stated they remember there was a year when the laundry machines were broken but the residents never run out of clean clothing because the laundry were dropped off and picked-up from the laundry service location by care staff assigned and were already washed and folded when picked-up. The 5 staff stated that during the previous years when facility had COVID-19 outbreaks and staff called off, the facility contracted with staffing agency. The PED stated that when she came on board in 2024, they didn't have problem with staffing and didn't utilize staffing agency. Due to medical diagnosis, LPA was not able to obtain information from the 2 residents. Therefore, the allegation is closed as unsubstantiated. Allegation: Staff are not following COVID protocols. RP stated there’s no designated area for the COVID-19 positive residents and staff work on both positive and negative residents. All 5 staff interviewed stated there was no cross-over of care staff from positive residents to negative residents or vice versa. The facility followed the protocol and guidance from Public Health, Community Care Licensing and Brookdale corporate. All these staff including the PED stated residents who tested positive of COVID-19 were isolated. They stated some residents who were on isolation due to medical diagnosis came out of isolation but when this happened, they redirected the residents back to their rooms or separate them from the negative residents in the common area. Due to medical diagnosis, LPA was not able to obtain information from the 2 residents. Therefore, the allegation is closed as unsubstantiated. ......continued on 9099C (page 4) Page 4 Based on interviews, observation and records reviews, the four allegations were closed as unsubstantiated as t here is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.