complaint·June 6, 2025

The allegation of “Staff did not ensure resident received wound care” alleges that the facility did not provide wound care for a wound on resident #1’s (R1) hand. LPA interviewed the Administrator who informed LPA that R1’s hand was in a cast after a fall that occurred before R1 was a resident of the facility. The Administrator denied R1 having any additional wounds. LPA reviewed R1’s file and hospital discharge paperwork. LPA did not observe any documentation of wounds that would require care. The Administrator stated that R1 wished to have the cast removed but R1’s physician required x-rays of the hand before an orthopedic doctor could remove the cast. LPA spoke with a representative from R1’s physician’s office witness #1 (W1) and was informed that R1’s family was provided referral orders for both the orthopedic doctor and x-rays. W1 confirmed that the referrals were provided to the family and not the facility. W1 stated that it was the family’s responsibility to set up the appointments and inform the facility of the time, date, and location of the appointments. W1 denied being aware of resident requiring care for any other wounds. The Administrator stated that they attempted to work with R1’s family to obtain a time, date, and location for the appointment but the family did not respond with the required information for the Administrator to assist with the appointments. The Administrator stated that R1 left the facility before the appointments for the x-rays and the orthopedic doctor could be made. No current residents interviewed reported having wounds that required care. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not ensure resident received wound care.” Therefore, the allegation is deemed Unsubstantiated at this time. Continued on LIC 9099C. The allegation of “Staff are not ensuring resident has clean bedding” alleges that the facility went extended periods of time without changing R1’s bedsheets. During the physical plant tour LPA observed six (6) resident beds throughout the facility. All bedsheets appeared to be clean. LPA interviewed three (3) residents. One (1) resident interviewed, resident #2 (R2), reported that bedsheets are changed at least once a week if not more often. One (1) resident interviewed, resident #3, (R3) reported that bedsheets are changed regularly. All residents interviewed denied not having their bedsheets changed for extended periods of time. LPA interviewed the Administrator who stated that they have cleaners that come to the facility every other day. The Administrator stated that the cleaner’s duties include changing the resident’s bedsheets and they are changed at minimum once a week. LPA observed the facility to be clean and well kept. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff are not ensuring resident has clean bedding.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Staff did not provide resident with a 60day notice to increase rent” alleges that the facility did not provide R1 with an appropriate 60-day notice of rent increase. LPA reviewed R1’s resident file. R1’s admission agreement dated 03/27/2025 revealed that R1 was to be charged $3500 for a shared room in the facility. During the interview with the Administrator, they informed LPA that R1 was initially being charged $2000 for a shared room due to special circumstances. The Administrator stated that R1 was supposed to be a short-term resident of the facility but when the time came for R1 to leave the facility R1 no longer wished to leave. The Administrator informed R1 that they would need to increase the rent of the bed to the amount agreed upon in the admission agreement. The Administrator stated that they provided a 60-day rent increase notice to R1 for the increase from $2000 to $3500 as agreed upon in the admission agreement. The Administrator provided LPA with a copy of the 60-day rental increase notice signed by both R1 and the Administrator dated 05/14/2025. The Administrator stated that the 60-day rental increase notice was to go into effect 60-days from the issuance of the notice but R1 voluntarily relocated from the facility on 05/29/2025 before the notice went into effect. The Administrator confirmed that R1 was never charged the $3500 amount for room rent as the notice had not yet gone into effect. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not provide resident with a 60day notice to increase rent.” Therefore, the allegation is deemed Unsubstantiated at this time. Continued on LIC 9099C. The allegation of “Staff did not ensure that there were not more than two residents in a room” alleges that the facility placed R1 into a room with two (2) other residents. During the physical plant tour LPA observed two (2) single occupancy rooms and two (2) dual occupancy room. LPA did not observe more than two (2) beds in any resident rooms. LPA interviewed three (3) residents. All three (3) residents denied having roommates. LPA interviewed the Administrator who denied having three (3) residents in any rooms. The Administrator stated that R1 was placed into a shared room while they resided at the facility. The Administrator stated that R1 was initially alone in the room but had a roommate move in while R1 was residing at the facility. The Administrator stated that R1’s roommate left the facility and no additional resident moved into the room until after R1 left the facility. During an interview with R1 they informed LPA Peraldi that they only had one (1) roommate during their stay at the facility. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not ensure that there were not more than two residents in a room.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Food being served to residents is not of good quality” alleges that the facility was not serving residents good quality food sufficient to meet their needs. During the physical plant tour LPA observed the facility’s refrigerator, freezer. And pantry. LPA observed a sufficient supply of two (2) days perishable and seven (7) days of non-perishable foods. LPA observed all foods to be stored in appropriately sealed containers. LPA did not observe any foods to be expired or stored in damaged containers. At approximately 01:15 PM LPA observed the facility’s lunch service to serve food of good quality and in sufficient amounts. LPA interviewed three (3) residents. All residents interviewed reported the food quality to be fine and reported that food is served in sufficient amounts. No residents interviewed had concerns with the quality or quantity of foods being served. LPA interviewed the Administrator who stated that R1 would request alternatives to the foods that were being served. The Administrator stated that on at least four (4) occasions they provided R1 with alternative foods from outside of the facility when they did not want what was being served. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Food being served to residents is not of good quality.” Therefore, the allegation is deemed Unsubstantiated at this time. A copy of the report was printed and exit interview was conducted.