Complaint·December 11, 2025

No staff were observed yelling at residents during the visit, and training records confirmed instruction on resident rights and respectful care. Records reviewed multiple in-service trainings teaching and reminding staff to treat residents with dignity and respect. Although the allegation may have occurred, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. Concerning the allegation that staff allow residents to smoke inside the facility. Interviews revealed that 1 resident agreed, 5 disagreed, and 1 did not respond; all staff (S1-S7) denied the allegation and confirmed that residents are consistently redirected to the designated outdoor smoking area. Records reviewed revealed that Admission agreements prohibit indoor smoking, and during the visit, residents observed smoking in the designated patio area. Although the allegation may have occurred, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. Regarding the allegation that staff did not meet residents’ toileting needs, it was alleged that R1’s toilet was not repaired in a timely manner. Interviews with residents (R1-R7) revealed that 6 residents disagreed and 1 agreed, noting the issue was resolved; among staff, 6 disagreed and 1 was unsure. Toilets were observed to be operational during the visit. The maintenance staff stated that the toilet was clogged and repaired the same day using a plumbing snake and confirmed that maintenance issues are often communicated verbally and not formally logged to address them quickly. A maintenance work log notebook is maintained at the facility, with entries dated 02/21/2024 to 09/22/2024, documenting completed task orders and corresponding room numbers. Although the allegation may have occurred, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. Based on observations, interviews, and records reviewed, there is insufficient evidence to support the allegations; therefore, the allegations are unsubstantiated. No deficiencies were cited during today’s visit, and an exit interview was conducted with the administrator.