Complaint·March 28, 2026

Allegation: License does not ensure that facility administrator is on the premises a sufficient number of hours . It was alleged that the facility does not have an Administrator/ ED on property. The Administrator is present less than 20 hours per week with no after-hours qualified Designee. EDs lack of presence in Memory Care demonstrates a disregard for accountability." Interviews with ED, other staff and facility residents revealed that ED is present in the facility sufficient number of hours. There are designated staff responsible for Assisted Living (AL) and Memory Care (MC) units. A review of facility staff schedule verified that there are specific personnel responsible to oversee the operations in AL and MC. There is no information to verify that ED is not precent in the facility as it is required. Therefore, based on interviews and record review, there is an insufficient information to verify the allegation, Hence the allegation is unsubstantiated at this time . Allegation: Facility staff do not answer communications from residents’ representatives appropriately . Allegation: Facility staff do not properly report unusual incidents . It was alleged that family and resident requests are ignored by ED. Incident reports with falls and hospitalization aren’t submitted because ED is too busy and she can’t approve “minor” issues. ED revealed that any incidents reflecting residents’ health and safety are being reported to residents’ responsible parties, medical providers, and appropriate agencies. Staff indicated that upon knowledge of the incidents involving residents, they immediately report to their supervisor or lead. Residents interviewed during investigation addressed no concerns about incidents reported to their responsible parties. During subsequent visit LPA Comer spoke with residents’ responsible parties and they verified that ED or designees are in communication with them if needed. A review of facility records, including internal incident log and Incidents reports did not provide any measurable and verifiable information to verify the allegation. Therefore, based on interviews and record review, the above noted allegations are unsubstantiated at this time . No immediate health and safety issues were noted during investigation. Exit interview was conducted and a copy of report was issued.