complaint·March 5, 2025

Licensee does not ensure that residents are provided with a comfortable temperature. Licensee does not ensure that the facility is kept clean and odor free Licensee does not ensure that staff follow proper sanitary food service protocols. Licensee does not ensure that food services provided to residents is adequate. Licensee did not ensure that resident received their mail. LPA and LPM conducted interviews and facility walk thru. Interviews with residents indicated resident’s have not had issues with the facility being at an uncomfortable temperature. Resident’s stated staff are consistent with cleaning their apartments as well as keeping common areas of the facility clean and sanitary. Resident’s stated they have not had issues with food service including temperature of food, quality and quantity of the food served. Lastly resident’s all have individual mailboxes where staff put resident’s mail when received. Resident’s did not indicate any issues with receiving their mail timely. During observations of the facility, LPA and LPM observed the facility clean and odor free. Facility was at a comfortable temperature during the visit. During the walk through of the facility kitchen area, LPA and LPM observed kitchen to be clean and sanitary. Food was observed to be labeled, covered and dated. Interviews with kitchen staff indicated food service staff have current food handler’s certificates. Based on interviews conducted and observation, the above allegations are found to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Questionable Death Records were reviewed regarding the death of R1. Based on documentation, R1 was on Hospice at the time of death. Records indicated R1 had a 1:1 aide (W1) present at the time of death. W1 noticed R1’s was unresponsive and contacted facility staff. Facility staff contacted Hospice. Once Hospice arrived at the facility, R1 was unresponsive and pronounced deceased. R1’s death certificate lists cause of death The above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility. Licensee does not ensure that residents' call pendant systems are operable. Licensee does not ensure that staff respond to residents' requests for assistance in a timely manner. A sample of resident call button response logs was reviewed. Based on call button logs, the typical response time for staff responding to a resident’s call alert ranges from 5–12 minutes. Residents interviewed stated they have not had issues with staff not responding to call buttons timely. Staff interviews indicated that staff usually respond to resident’s call buttons within 10-15 minutes. Staff did state that occasionally after assisting a resident, staff will forget to clear the call button request whereas documents may seem that resident’s are waiting for assistance longer. Based on records reviewed and interviews conducted, resident call pendant systems are operable and staff are responding to residents in a timely manner. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Report left with facility.