complaint·September 11, 2025

In regard to the allegation “Resident does not have a call signal button in the room”, it is alleged that there is no call button in residents’ room and residents must call facility phone number to request assistance with care. During interviews with staff six (6) out of six (6) stated that all bedrooms are provided with a pull cord in bathrooms. S1 stated that residents are assessed and if determined that a resident is frail and in need of additional assistance a call pendent is provided. Staff stated residents call on their cell phones or room phones if assistance is needed. LPA observed five pull cords in residents’ bathrooms. During interviews with residents four (4) out of five (5) residents stated that they all have pull cords in restrooms and if needed they use their phones for assistance. LPA was not allowed entry in R1’s bedroom and a request for an interview was denied. In regard to the allegation “Resident is not being provided assistance per care and needs plan”, it is alleged that resident is not being provided adequate assistance with transfers from bed to wheelchair due to R1 being tall and caregivers being too small for his/her weight. During interviews with staff six (6) out of six (6) stated that there is enough staff to properly transfer all clients, and facility even has Hoyer lifts if needed. All staff stated that residents care and needs plans are being followed. During interviews with residents five (5) out of six (6) residents stated that all of there care and needs are being met by staff. LPA attempted to interview R1 but was denied. In regard to the allegation “Staff entered resident's room without permission resulting in broken furniture”, it is alleged that staff broke a residents table when cleaning room. During interviews with staff five (5) out of six (6) staff stated that to their knowledge nothing has been broken in resident’s bedroom. S1 stated that he/she did hear of an allegation of a broken table, but no proof was ever submitted. During interviews with residents three (3) out of six (6) residents stated that they have never had anything broken due to a staff entering their room. Two (2) residents stated that a small Christmas decoration and a bidet was accidentally broken when housekeeping was cleaning but not on purpose. LPA attempted to interview R1 but was denied. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided.