complaint·July 10, 2025

Regarding the allegation, “Staff did not ensure resident was assisted in a timely manner,” it is being alleged that Resident #2 (R2) was not ready for scheduled pick-up on 06/24/25. Record review of R2’s Physicians’ Report revealed that R2 is able to dress and groom self, able to communicate, and leave the facility unassisted. Interview with Wellness Director indicated that R2 is independent. Wellness Director indicated that when a resident is independent, appointments are not tracked unless the facility is providing transportation. Four out four staff interviews (S2 – S5) indicated that staff communicate with each other to have the resident prepared for timely pick-ups. One out two resident interviews (R3 – R4) indicated that staff have them prepared for pick-ups. Three out of three resident interviews (R1- R2, R7) indicated that they are independent. Witness #1 indicated that resident is assisted in a timely manner. Regarding the allegation, “Staff did not ensure resident was assisted in a timely manner,” based on interviews and record review, the Department found no evidence to support the allegation mentioned above. 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. Regarding the allegation, “Staff do not provide activities for residents,” it being alleged that on several occasions, wheelchair-bound residents were placed in front of the television for an extended period of time instead of being engaged in other activities. Record review of January through March 2025 activity schedule revealed that activities were scheduled from 9:00 AM – 6:30 PM from Sunday through Tuesday, Thursday, and Saturday. Activities were scheduled from 9:00 AM – 8:00 PM on Wednesdays and Fridays. Record review of April - June 2025 activity schedule revealed that activities were scheduled from 9:00 AM – 6:30 PM from Sunday through Tuesday and Thursday through Saturday. Activities are scheduled from 9:00 AM – 6:00 PM on Wednesdays. Five out five staff interviews (S2 – S6) indicated that residents in wheelchairs are provided with activities. Interview with the Activities Director indicated that all residents in wheelchairs or diagnosed with dementia are encouraged to participate in events and outings. Seven out seven resident interviews (R1 – R7) indicated that staff provides residents with activities. Witness #1 indicated that the facility provides activities. LPA observed residents engaged in activities located in the common areas. Regarding the allegation, “Staff do not provide activities for residents,” based on interviews, record review, and observations, the Department found no evidence to support the allegation mentioned above. 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. Continue to LIC9099-C. Regarding the allegation, “Facility elevator is in disrepair,” it is being alleged that the elevator was not working in early June 2025. Record review of elevator service contract revealed that the facility has a maintenance service agreement throughout 2025. Interview with the Maintenance Director indicated that the elevator was operable in June and whenever there is an issue, it is resolved right away. Four out four staff interviews (S2 – S3, S5, S7) indicated that the elevator was operable in June. LPA observed a evacuation wheelchair in stairwell 1 and 2. Four out five resident interviews (R1 – R3, R5, R7) indicated that the elevator was operable in June. R4 and R6 were unaware if the elevator was or was not operable. Witness #1 indicated that the elevator was operable in June. Regarding the allegation, “Facility elevator is in disrepair,” based on interviews, record reviews, and observations, the Department found no evidence to support the allegation mentioned above. 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. Regarding the allegation, “Facility does not conduct emergency drills as required,” it is being alleged that the facility has never conducted a fire drill. Record review of fire drill report revealed that seven residents and staff participated in a drill on May 25, 2025 in the evening. Fifteen residents participated in the fire drill on February 12, 2025 in the morning. The document also revealed that some residents did not want to participate. Six out six staff interviews (S2 – S7) indicated that the facility conducts drills. Witness #1 indicated that W1's father does not participate in fire drills. Three out five resident interviews (R1, R3, R5 – R7) indicated that the facility has fire drills. Two out of two residents (R2, R4) were unaware if the facility conducted fire drills. Regarding the allegation, “Facility does not conduct emergency drills as required,” based on interviews, record reviews, and observations, the Department found no evidence to support the allegation mentioned above. 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. No deficiencies were issued. An exit interview was conducted and a copy of this report was provide to the Wellness Director Michelle Brown.