Complaint·August 8, 2024

CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility is not providing special diet meals to residents diagnosed with diabetes , the following has been concluded: Based on interview with facility kitchen staff as well as observation of the kitchen special diet information, meal service and resident interviews, it was determined that special diet residents are placing their orders via the facility caregivers prior to the meals being prepared. Diet-appropriate substitutions are made. Regarding the allegation that Facility is not providing adequate laundry services , the following has been concluded: During the facility visit, LPA accompanied by facility staff toured the dedicated laundry area used by memory care staff on the ground level as well as the assisted living laundry area which is located on the third floor of the physical plant. In both instances, the laundry areas observed are found to have clean, sanitary and odorless floor surfaces. Laundry equipment is also observed to be in good repair. Per a sample admission agreement reviewed and interview conducted, residents are receiving laundry services with no additional cost on a weekly basis. Regarding the allegation that Licensee does not ensure infection control practices are maintained : At the time of the visit, one final resident was stated by facility staff to be coming off of the mandated isolation period. Isolation signs as well as appropriate PPE for staff coming in was still present on the resident's unit doorstep. Per documentation provided, facility staff has been reporting cases to public health authorities and conducting the recommended measures to limit transmission. Regarding the allegation that Resident records are not stored in a confidential manner , the following has been concluded: Based on a complete tour of the facility's physical plant, resident records were observed to be kept in individual folders located in either the assisted living or the memory care medication rooms on the first and second level of the facility. Both locations are either accessed via staff keys or a back-up code or fob. The entry to both medication rooms was verified to be locked and inaccessible. No other records were present or observed in any other area of the facility at the time of the visit. Based on the above evidence, the four allegations listed are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility. CONTINUED FROM AMENDED FORM LIC9099-A Regarding the allegation that Facility does not have a certified administrator , the following has been concluded: LPA reviewed the listing of pending applications for the renewal of RCFE Administrator certifications maintained by the Department's Administrator Certification Bureau prior to the visit and verified that the facility's Executive Director was listed on the Department's pending applications currently in review. Proof of submission of a complete application dated December 12, 2023 was provided during the facility visit. The certification was at the time valid until April 18, 2024. A new certification number valid from April 19, 2024 until April 18, 2026 was issued by the Department. It is therefore confirmed that the facility's Executive Director is in possession of a valid RCFE Administrator certificate at the time of the visit. The allegation is therefore found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint. An exit interview was conducted and a copy of this report was provided to a facility representative.