Complaint·April 29, 2026

Regarding the allegation: Staff did not ensure the residents had running water. It is being alleged that resident #1 (R1) had no water. During LPA’s interview with R1, “they stated that they did not have running water for the weekend of 03/07/26-03/08/26 and could not take a shower.” During LPA’s physical tour on 03/10/26, LPA tested the water in R1’s bathroom and R1 had water in the shower area but not the sink/handwashing area. Also, LPA received an Unusual Incident report on 03/06/26, stating that water was going to be shut off for about thirty (30)-sixty (60) minutes but not for the entire weekend. LPA interviewed an additional fifteen (15) residents that confirmed they did not have water that weekend. LPA interviewed three (3) staff that confirmed there was no water that weekend. Therefore, based on the observation and interviews conducted, the allegation is SUBSTANTIATED at this time. Regarding the allegation: Staff did not respond to a resident's call button in a timely manner resulting in not meeting resident's medical needs. It is being alleged that resident #1 (R1) fell, used their emergency call button, and nobody came to help them, leaving R1 on the floor for hours. During LPA's interview with R1, R1 stated, "they were left on the floor for several hours because no staff responded when they pressed their pendant." During LPA’s physical tour on 03/10/26, LPA pressed the emergency call button in R1’s bathroom and no one responded. In addition, LPA pressed R1’s pendant and no staff responded. As a result, it was determined that R1's pendant and call button were not working and that was the reason for not meeting R1's medical needs. LPA interviewed three (3) caregivers that confirmed it depends how many resident's they have to care for, what they need and them communicating to another caregiver if they are currently busy prolongs the time to respond to the call buttons. Although, LPA interviewed an additional fifteen (15) residents that confirmed their pendants and call buttons work because they use it and staff respond to them the allegation is still substantiated based on R1's malfunction of equipment in their room. Therefore, based on LPA's observation of R1's pendant and call button not functioning and interviews conducted, the allegation is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, an appeals right was provided and a copy of this report was given to the Executive Director. Regarding the allegation: Staff do not keep the facility free from infestation. It is being alleged that resident #1 (R1)’s bed and room is full of roaches and bed bugs. During LPA’s physical tour on 03/10/26, LPA did not observe any roaches and/or bed bugs in R1’s room and/or bed. In addition, R1 could not find the pictures on their phone that they said had proof of roaches and bed bugs. Furthermore, ECOLAB PEST conducted a visit on 03/06/26, and there was no rodents and roaches in R1’s room. LPA received a copy of the ECOLAB PEST paperwork. Although R1 did not have bed bugs, the above facility gave R1 a new bed on 03/10/26 . During another facility visit conducted on 03/18/26, LPA visited R1 and LPA observed the new bed that was given to them. LPA interviewed an additional fifteen (15) residents that confirmed they have not seen any roaches in their room, and they do not have bed bugs. LPA interviewed three (3) staff that confirmed they have not seen any roaches and/or bed bugs in R1's room and throughout the facility. Therefore, based on the observations and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not properly maintain the facility grounds. It is being alleged that poop and other fluids are smeared on the floor. During LPA’s physical tour on 03/10/26, LPA did not observe any poop and/or other fluids smeared on the floor of the facility. In addition, LPA conducted another physical tour on 03/18/26 and 04/29/26 , and again LPA did not observe, and poop and/or other fluids smeared on the floor. LPA interviewed sixteen (16) residents that confirmed they have not seen any poop and/or other fluids smeared on the floor. LPA interviewed three (3) staff that confirmed the facility is cleaned several times per day and per shift. Therefore, based on the observations and interviews conducted, the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff did not provide laundry services for a resident. It is being alleged that staff are refusing to do resident #1 (R1)’s laundry. During LPA’s interview with R1, R1 admitted, “that they did not know their scheduled laundry day before but now know that it is on Thursdays. LPA received a copy of the laundry schedule, and it was confirmed that R1’s laundry day is on Thursdays. LPA interviewed an additional fifteen (15) residents that confirmed they know their laundry day and laundry services are provided to them on a certain day. LPA interviewed three (3) staff that confirmed weekly laundry is done for residents. Therefore, based on the interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not timely address a resident's change in medical condition. It is being alleged that resident #1 (R1) had an eye infection and was not being treated. During LPA’s interview with R1, R1 did say that they had recently had an eye infection and had let the facility doctor know and an antibiotic had been ordered but it was taking too long for them to receive. During LPA's physical tour on 03/10/26, LPA did observe R1’s left eye to be a little red. During R1’s medication review, R1’s ointment was ordered on 03/09/26 and was provided to them within the next couple days following approval. During LPA’s physical tour on 03/18/26 and 04/29/26, LPA observed R1’s eye not infected anymore. Furthermore, an additional ointment was prescribed for R1 on 04/22/26. LPA interviewed an additional fifteen (15) residents that confirmed they receive their prescriptions in a timely manner and the staff address their change in medical condition. LPA interviewed two (2) medical technicians and two (2) licensed vocational nurses that confirmed R1 is getting ointment medication for their eye. Therefore, based on the observations and interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Executive Director.