complaint·October 3, 2025

Investigation revealed the following: Allegation: “Staff did not provide meals to residents in care in a timely manner”, it is being alleged that meals take 30 minutes up to an hour to be served. Interviews conducted with R1 to R10 revealed the following: 10 out of 10 residents denied the allegation. Interviews conducted with S1 to S7 revealed the following: 7 out of 7 staff denied the allegation. Interviews conducted with W1 to W7 revealed the following: 7 out of 7 witnesses denied the allegation. Records Reviewed of the “New Resident Welcome Packet” under “Dietary Services” states the following: Breakfast is served at 8:00 am, Lunch is served at 12:00 pm, and Dinner is served at 5:00 pm. Observations on 10/02/205 during lunchtime revealed the following: the dining room tables were set up at around 11:30 am; the dining tables had placemats, and each placemat had cutlery set up, a cup of water and a cup of juice; residents started to go into the dining room at around 11:35 am; a caregiver left the dining room with a mobile food tray carrier at around 11:40 am and then again around 11:50 am; the serving staff started serving soup, salad, and coffee at around 11:57 am; the serving staff started serving entrees at around 12:13 pm; the serving staff started serving desert at around 12:20 pm. Observations on 10/02/205 during dinner time revealed the following: the dining room tables were set up for at around 4:20 pm; the dining tables had a placemats, and each placemat had cutlery set up, a cup of water and a cup of juice; residents started to go into the dining room at around 4:30 pm; the serving staff started serving residents starters at around 4:50 pm. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not provide medication assistance to residents in care in a timely manner.” Interviews conducted with R1 to R10 revealed the following: 10 out of 10 residents denied the allegation; furthermore, residents indicated that they receive their medication. Interviews conducted with S1 to S7 revealed the following: 7 out of 7 staff denied the allegation, furthermore, staff indicated that they have not heard of any complaints regarding this allegation. Interviews conducted with W1 to W7 revealed the following: 7 out of 7 witnesses denied the allegation, moreover, witnesses indicated that the facility does a good job at providing residents with medication and calling them if the resident requires a refill. Observations on 10/02/205 revealed the following: at around 11:20 am the Medication room was toured, and it was organized; at around 11:40 am MedTech’s started passing out medications in the dining room and finished passing out medications around 12:37 pm; at around 4:35 pm MedTech’s started passing out medications in the dining room. Records reviewed of Medication Administration Records (MARs) for R1 to R10 revealed the following: there is no documentation indicated that medications were not passed out on time. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “ Staff are not able to properly transfer residents in care due to lack of staffing”, it is being alleged that when using Hoyer lifts only one staff uses the equipment instead of two staff. Interviews conducted with R1 to R10 revealed the following: 9 out of 10 residents denied the allegation; 1 out 10 residents did not know how many staff use the Hoyer lift when transferring residents. Interviews conducted with S1 to S7 revealed the following: 7 out of 7 staff denied the allegation, furthermore, staff indicated that they have not seen or heard of only one staff member using the Hoyer lift. Interviews conducted with W1 to W7 revealed the following: 7 out of 7 witnesses denied the allegation, moreover, witnesses indicated that they have seen two staff members using the Hoyer lift and/or have not seen only one staff member using the Hoyer lift. Residents’ records reviewed revealed the following: R1 to R10 have doctors’ orders for Hoyer lifts. Staff records reviewed revealed the following: staff training on “Caregiver Safety Tips” which includes how to use a Hoyer lift; staff signatures acknowledging the following “I acknowledge that I will always call for another person to help when operating the Hoyer lift and agree to follow company policy at all times. I acknowledge that I received a handout of this policy”; staff signatures acknowledging that that they have received and read the “Employee Handbook”, which includes a section of mandatory “Training and Education.” Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff vape inside the facility.” Interviews conducted with R1 to R10 revealed the following: 9 out of 10 residents denied the allegation; 1 out of 10 residents were unable to answer the question. Interviews conducted with S1 to S7 revealed the following: 7 out of 7 staff denied the allegation. Interviews conducted with W1 to W7 revealed the following: 7 out of 7 witnesses denied the allegation. Observations on 10/02/2025 and 10/03/2025 revealed the following: no staff, residents, nor visitors were observed smoking/vaping inside the facility. Staff records reviewed revealed the following: “Drug Free Workplace Policy” with staff signatures; “Code of Conduct” in the workplace; and staff signatures acknowledging that that they have received and read the “Employee Handbook”, which includes a section on “Drug-Free Workplace.” Based on the department’s interviews and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were provided. An exit interview was conducted, and a copy of this report was left with the Resident Care Coordinator, Corina Khal.