complaint·September 4, 2025

Interview with Visitor #1 (V1) at 12:35 p.m. on 02/07/25 revealed staff put the soiled sheets in the corner of R1’s closet since the laundry basket was overflowing. LPA smelled a faint odor of urine coming from the soiled sheets. Interview with a previous administrator revealed they received a report from S2 that there was a resident who did not receive laundry service in a timely manner. Staff #5 (S5) was the normal laundry staff at the facility, and Staff #6 (S6) was supposed to clean the laundry while S5 was out of the facility. Interview with S2 revealed that “2-3 residents have piles of laundry” in their rooms. Interview with S5 at 12:15 p.m. on 02/06/25 revealed they were hired a few weeks prior to clean laundry after the previous laundry staff left. S5 showed LPA the laundry schedule and stated R1’s laundry is scheduled to be cleaned on Sundays. The facility does not wash laundry on Fridays or Saturdays. When residents soil their sheets, the facility provides fresh sheets, though the resident may have to wait until their scheduled laundry day to have their linens cleaned due to the laundry schedule being full. S5 confirmed that two (02) weeks prior, around 01/27/25, they called out from work and left a note for S6 to do R1’s laundry. When S5 returned to work, they noticed R1’s laundry was not washed. R1 had to wait another week for laundry service due to a full laundry schedule. Based on observations, interviews, and record review, staff did not meet R1’s laundry needs. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on the LIC 9099-D page. No immediate health or safety hazards observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided. LPA’s first call was not answered. LPA was unable to leave a voicemail because the voicemail inbox was full. Staff #1 (S1) answered the call at 8:55 a.m. LPA also called the facility phone at 8:33 a.m. and 8:34 a.m. on 02/07/25. LPA’s call at 8:33 a.m. was not answered, and the voicemail box was full again. Staff #4 (S4) answered LPA’s call at 8:34 a.m. and noted they were opening the garage gate at 8:33 a.m. and were away from the front desk. Interview with a previous administrator at 11:10 a.m. on 02/06/25 revealed that the facility has one phone line which the concierge answers. If the concierge does not answer a call, it also goes to the Wellness office where staff are trained to answer calls and clear the voicemail each day. Residents can call out from any facility phone, but incoming calls must be answered by staff so that residents can receive their calls. If staff do not answer the phone, residents have no way of receiving calls intended for them. Interview with S1 at 11:40 a.m. on 02/06/25 revealed that their concierge shift starts at 9:00 a.m. S1 confirmed that staff in the Wellness office should answer the call when concierge is not present. S1 also stated they clear the voicemail everyday and there may have been technical issues. Interviews with Staff #2 (S2) at 11:50 a.m. on 02/06/25 and Staff #3 (S3) at 11:55 a.m. on 02/06/25 confirmed that concierge should answer calls, and S2 and S3 can answer the call if concierge misses it. S2 and S3 were not aware of any missed calls from the morning. LPA tested the phone system this morning at 9:22 a.m. Staff #4 (S4) answered promptly. Based on observations and interviews, staff ensured the phone was answered. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff are not ensuring the facility is kept clean" it was alleged the floors are dirty and have crumbs on them. Facility tours on 02/06/25, 02/07/25, and today revealed no dirt, stains, or crumbs were observed on facility floors. LPA interviewed nine (09) out of ninety (90) residents, which was 10% of the census. Interviews with six (06) out of nine (09) residents interviewed revealed that they had no issues with the cleanliness of the facility or the floors. Interviews with three (03) out of nine (09) residents interviewed revealed that there are deep stains in the carpets despite facility staff frequently cleaning the carpets. Interview with a previous administrator at 11:10 a.m. on 02/06/25 revealed housekeeping sweeps and vacuums common areas everyday. The Maintenance Director deep cleans the common areas every week. Interviews with maintenance staff, Staff #7 (S7) at 11:30 a.m. on 02/06/25 and Staff #8 (S8) at 12:40 p.m. on 02/06/25 confirmed that the common areas are deep cleaned on a weekly basis. Based on observations and interviews, staff ensure the facility is kept clean. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not ensure there is an activities director" it was alleged the facility has no activities director. Interview with a previous administrator revealed Staff #9 (S9) has been the activity director for about one (01) year. Record review of the staff list confirmed S9 has been the activity director. Interview with S9 at 11:05 a.m. on 02/07/25 confirmed they are and have been the activity director. Based on interviews and record review, the facility has an activity director. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not ensure resident's shower was not in disrepair" it was alleged the shower handle in the bathroom belonging to Resident #1 (R1) was broken for multiple weeks. Tour of R1’s room at 12:30 p.m. on 02/06/25 revealed their shower handle was functioning properly. Interview with the former administrator revealed they had not received any reports of necessary maintenance in R1’s room. Interview with S8 revealed they first received the maintenance order from caregivers on 02/06/25. S8 showed LPA proof of the work order for R1’s shower handle at 11:09 a.m. on 02/06/25. S8 and S7 fixed the issue by 12:00 p.m. on 02/06/25. LPA attempted to interview R1 at 12:40 p.m. on 02/06/25 but received no relevant information. Interviews with nine (09) out of ninety (90) residents revealed that they had no maintenance issues. Based on observations, interviews, and record review, the facility ensured R1’s shower handle was fixed promptly after receiving the work order. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.