complaint·September 4, 2025

Allegation: Facility does not employ enough staff to meet the residents' needs. It is being alleged that the facility is short staff, which causes the residents not to receive services such as having resident bedrooms cleaned properly. On 08/20/25 from 1:00pm-2:30pm LPA Villegas conducted interviews with R1-R10 regarding the allegation above. 10 of the10 residents interviewed denied the allegation above, however 1 of 10 residents reported staff is removing trash can from resident’s bedroom without consent. On 08/20/25 while conducting tour of the facility LPA observed housekeeping staff cleaning bedrooms on both the first and second floors. On 08/20/25 LPA conducted a review of the staff schedule provided; LPA observed there are 4 direct care staff, 1 med tech, and 4 supervisors from 6am-2pm, 4 care staff, and 1 med tech scheduled from 2pm-10:30 pm, and 3 care staff, and 3 med techs scheduled from 10pm-6:30am. On 08/20/25 LPA reviewed the housekeeping schedule, LPA observed that there are 3 housekeepers on shift in the morning, and each housekeeper is scheduled to clean 5-6 bedrooms each daily. On 08/20/25 and 09/04/25 LPA conducted interviews with S1-S5 regarding the allegation above 3 of the 5 staff interviewed denied the allegation above, 2 of 5 staff interviewed reported having no knowledge of resident bedroom cleaning procedures. Allegation: Staff do not provide assistance to residents in a timely manner. It is being alleged that residents in care must wait up to an hour to receive the requested services such as obtaining a clean towel. On 08/20/25 from 1:00pm-2:30pm LPA Villegas conducted interviews with R1-R10 regarding the allegation above. 9 of the 10 residents interviewed denied the allegation above and reported waiting a few minutes when requesting linen supplies from staff. 1 of 10 residents interviewed confirmed the allegation above. On 08/20/25 and 09/04/25 LPA conducted a pull cord response test, staff were observing responding to pull cord within 6-10 minutes. On 08/20/25 and 09/04/25 LPA conducted interviews with S1-S5 regarding the allegation above 3 of the 5 staff interviewed denied the allegation above and reported linen and towels are exchanged weekly, however residents are provided with additional linen supplies upon request. 2 of the 5 staff interviewed reported having no knowledge of linen exchange procedures. Allegation: Staff do not provide residents with adequate food service. It is being alleged that residents in care do not have access to water, and menu options are decreasing. On 08/20/25 from 1:00pm-2:30pm LPA Villegas conducted interviews with R1-R10 regarding the allegation above. 9 of 10 residents denied the allegation above, 9 of 10 residents reported being able to choose meals from an alternative menu and reported having access to water. 1 of the 10 residents interviewed confirmed the allegation and reported that non ambulatory residents must wait long periods of time for staff to provide meals and beverages. On 08/20/25 and 09/04/25 LPA observed lunch service, LPA observed 1 staff member preparing meal trays, 2 staff members providing meal trays to the residents, and 2 staff members pushing carts that obtained an assortment of beverages. LPA reviewed the facility monthly menus as well as the alternative menu, LPA observed that the menu items are different every day. LPA also observed that the meal and snack portions are being provided to residents as instructed by dietician. On 08/20/25 LPA also conducted a review of the alternative menu, LPA observed that the alternative menu went from 6 options to 4 options. Per 3 of 5 staff interviewed 2 items were removed from the alternative menu due to those items not being requested by residents. On 08/20/25 and 09/04/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of the 5 staff interviewed denied the allegation above and reported there are water stations located in the lobby for residents to self serve, there is water in the med room, and in the dinning room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.