complaint·March 19, 2025

meals and respond to their pendant calls in a timely manner. Seven of seven residents stated that they feel safe at facility and are not in any danger. Based off interviews with staff, Ten of ten staff members stated that they feel they are meeting the care needs of residents. Based off Staff interviews, staff stated they are providing residents with assistance in Activities of Daily Living (ADL’s) and stated that they have not had any complaints from residents or family members on the level of care being provided. Regarding allegation “Staff do not have access to supplies for residents”, during visit, LPA observed that residents have supply of diapers, wipes, toilet paper, under pads, towels and linens inside resident rooms. During tour LPA Tirre observed storage closets that had extra over flow of diapers, under pads, wipes, incontinence products and gloves that are secured. LPA Tirre observed additional overflow of supplies readily available to staff near hydration stations as well as personal laundry room cabinets inside memory care wing. Based off interviews with seven residents, no residents stated they have been short supplied on items. Based on interviews with Staff members, ten of ten staff stated that residents have supplies of diapers, wipes, toilet paper, and towels readily available inside resident rooms. Nine of ten staff stated that facility has overflow of supplies inside storage closets which Director, Coordinators, Nurses and Med Technicians have keys to open for staff to access. Nine of ten staff interviews confirmed that residents under hospice care are being provided products from hospice agencies and residents not on hospice that require diapers, wipes and under pads are being supplied products from responsible parties. Staff interviews reveal that if ever an emergency need and resident does not have supply, staff will pull from overflow storage. Interview with Executive Director Modugno confirmed that facility started labeling supplies for each resident that requires incontinence supplies and that since, facility has not ran out of supplies for residents. Based on observations made and interviews conducted, LPA is unable to corroborate allegations made that staff not meeting residents needs and staff do not have access to supplies therefore 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 above allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Sara Modugno, and a copy of this report was provided during this visit.