complaint·March 20, 2026

LPA interviewed five residents who confirmed they get three meals a day and they have access to additional food in fridges located in lounge & memory care unit. LPA toured the facility and observed two refrigerators: one on the first floor near the lounge area containing food items such as sandwiches, pudding, apple juice, and orange juice, and another refrigerator in memory care unit offering the same. The facility menu was observed and found to reflect residents’ dietary plans. A review of the facility’s quarterly dietitian report, completed by the Dining Manager, showed that the facility received a passing score of 47.5 out of a possible 52 point Regarding the allegation that staff are not meeting residents’ toileting needs, the investigation determined as follows: LPA interviewed five staff members who reported they conduct resident checks approximately every two hours and more if required. Staff members further reported residents have the ability to call for assistance if needed. Two of the five staff interviewed reported direct knowledge of R1. Progress notes dated July 2, 2021, documented that staff attempted to assist R1 with hygiene and a shower, but R1 refused care and repeatedly asked staff to leave the room. LPA interviewed five residents who reported if they required help, they would receive it from facility staff. Residents reported staff check on residents throughout the day. Facility records confirmed that staff maintain a log for memory care resident two-hour checks. Facility does not maintain a log for facility Assisted Living resident checks. LPA tested facility pull cords in residents rooms and observed staff responding timely during visits. Regarding the allegation that staff failed to prevent inappropriate behaviors between residents, interviews were conducted with five staff members of which two reported knowledge of a verbal altercation between R1 and resident 2 (R2). Staff reported when the incident occurred residents were separated and no further incidents occurred. Staff denied that any physical interaction occurred between the two residents. LPA also interviewed five residents, all of whom stated they had no knowledge of any physical or verbal altercations between residents. A review of the facility’s Progress Notes revealed no evidence to support the allegation. Additionally, Progress Notes for Resident 1 (R1) showed no further incidents of aggression toward peers or staff. {***CONTINUE 9099C***} {***THIS IS AN AMENDED REPORT***} Regarding the allegations that facility walls and floors are dirty, LPA interviewed five staff members who reported the facility has housekeeping and maintenance. Housekeeping cleans resident rooms, common areas and bathrooms daily and clean additionally as needed. LPA interviewed five residents, who reported their rooms are cleaned regularly and have no observed dirty walls or floors. Resident rooms are cleaned on a schedule. LPA toured the facility and observed that the walls and floors were clean meaning free of graffiti and no chipped paints. LPA observed the facility to be free of odors. Review of housekeeping and maintenance logs indicated the facility follows a scheduled cleaning routine performed by designated maintenance staff. Based on the investigation, there was insufficient evidence to prove that the alleged violations occurred. Therefore, the allegations: Staff did not prevent inappropriate behaviors between residents,” “Staff are not providing adequate food service for residents,” “Staff are not meeting residents’ toileting needs,” “Facility walls are dirty,” and “Facility floors are dirty” are deemed Unsubstantiated. An exit interview was conducted with Executive Director (ED) Peggy Ulland and a copy of this report was provided to the facility representative. {***THIS IS AN AMENDED REPORT***}