complaint·October 8, 2025

Of the thirteen (13) residents interviewed, twelve (12) denied the allegation and reported receiving meals regularly; one (1) resident agreed with the allegation. Records reviewed included diet reports for bedridden residents, a meal tracking roster, and a resident service refusal form documenting when meals were declined. Although the allegation ‘Staff are not ensuring the residents are being fed’ may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. Regarding allegation “Staff allow smoking while residents are present”: Observations revealed that residents were smoking only in designated outdoor patio areas. No smoking was observed in prohibited areas or near non-smoking residents. Records reviewed included a resident acknowledgment form confirming receipt of a written warning regarding prohibited indoor smoking, indicating that the facility is enforcing its smoking policy. Interviews revealed that two (2) out of thirteen (13) residents agreed with the allegation, while eleven (11) denied it. Although the allegation “Staff allow smoking while residents are present” may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. Regarding allegation “Staff allows a resident to threaten other residents”: Observations conducted during the visit revealed no immediate or potential threats to resident safety. Records reviewed included incident reports documenting that behavioral concerns were reported and addressed by facility staff. Interviews revealed that Nine (9) out of thirteen (13) residents denied the allegation and reported feeling safe in the facility; four (4) residents agreed with the allegation. Although the allegation “Staff allows a resident to threaten other residents” may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the Resident Service Wellness Director.