Complaint·August 28, 2025

Allegations: “Staff due not ensure required posters are placed in the facility,” “Staff do not ensure facility has scheduled activities for residents,” “Facility does not ensure residents receive 3 meals per day,” “Licensee does not ensure staff are able to communicate with residents,” and “Staff do not ensure residents are provided clean linens.” It was reported that the facility staff removed state required postings off the walls. During the LPA’s tour of the facility, required postings were observed throughout the living room and were within the required dimensions per regulation. Interview with Resident #1 (R1) revealed that the required postings were allegedly taken down on 08/17/2025 and recently posted again. The LPA conducted an unannounced annual visit at the facility on 08/20/2025 and observed required postings at that time. Staff #1 (S1) confirmed that required postings remain on the walls in the living room and dining room. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. The facility allegedly advertised activities in their brochure, however, do not have any activities planned for the residents. During today’s visit, the LPA observed activity schedules posted throughout the facility in addition to activities conducted throughout the morning which consisted of music and dancing. Residents from the facility and subsequent facilities participated in the activity apart from residents who refused. Interview with four (4) staff and one (1) resident revealed that activities are scheduled every day between 11:30AM and 12:30PM with additional independent and optional group activities throughout the remainder of the day. Resident #2 (R2), S1, Staff #2 (S2), the CM, and the Licensee stated activities include but are not limited to music, dancing, physical exercise, puzzles, trivia, bingo, coloring, and cooking activities. The facility also works with a third-party vendor that provided two (2) activity directors that facilitate all activities for residents. Report Continued on LIC 9099-C R1 stated that today’s scheduled activity was trivia games, and they expressed that they did not observe any trivia games occurring. The LPA asked whether R1 goes outside to the shared courtyard between 11:30AM and 12:30PM to which R1 answered they do not, and they must have missed the activity. R1 expressed that they like to water plants and feed the squirrels and birds in the morning, which the facility encouraged, and the facility grounds contained various plants and fruit trees. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. It was reported that the facility only provided the residents two (2) meals a day which included breakfast and lunch at 3PM. The facility provided three (3) meals a day in addition to snacks in between each meal, per S2. S1 stated that meals are provided to residents who tend to sleep in or are unavailable during the scheduled mealtimes. Mealtimes are scheduled as follows: breakfast between 8AM and 9AM, lunch between 12PM and 1PM, and dinner between 4:30PM and 5PM. R2 confirmed the facility provided three (3) meals every day in addition to snacks and that staff accommodate to meal requests. Interview with R1 revealed that they are provided with breakfast and lunch, however, choose not to eat dinner because they are full from lunch. Additionally, R1 expressed they do not eat past 6PM due to scientific research theories. At 12:50PM, R1 was offered lunch and expressed that the food looked very good and that they have gained significant weight since residing at the facility. The Licensee shared that they grocery shop for all their facilities every other week and do not charge residents extra for ingredients for special meal requests. The CM reported that the facility also provided families who visit the facility meals during their visit and will typically send them home with food to go. The LPA observed sufficient food of good quality in the kitchen. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C It was alleged that facility staff do not speak English and cannot communicate with residents. Interview with staff revealed that most staff are fluent in English and there are a few who know basic English and can communicate well with the residents. The CM stood by during S2’s interview to assist with translation, however, S2 was able to communicate with the LPA in English and translation was not needed. S2 stated that they are typically paired with other staff that are fluent in English to utilize as a translator. They expressed that they know their residents very well and can meet their needs with no issues. S1 was fluent in English and expressed that all staff communication ranges from basic phrases to fluent. R2 expressed no issues in communication with staff. Witness #1 (W1) stated they regularly visit the facility and expressed no concerns about the facility and its staff and expressed gratitude to multiple staff. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. The facility allegedly did not provide clean linens to residents and did not change soiled sheets regularly. During the visit, the LPA observed all residents with clean linens and extra linens stored in each room. S1, S2, the CM, and the Licensee reported that linens are scheduled to be changed twice a week and if linens are observed to be dirty, staff will provide clean linens immediately. R1 reported they have not observed staff change their linens and was persistent on this notion due to their linens showing “the same wrinkles.” R2 stated their linens get changed regularly and has never had issues with having soiled linens. W1 stated they observe staff cleaning the facility often when they are visiting and have no concerns about the facility’s cleanliness. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.