Complaint·June 28, 2025

On 6/25/2025, the Department conducted a telephone interview with Executive Director Judith Pierfax (A1). On 6/27/2025 the Department reviewed electronic copies of the following pertinent documents: Staff schedule and roster (date 6/26/25), Resident roster (dated 6/26/25), Facility’s Fall Policy (dated 3/1/2025), Emergency and call system monito r ing policy (date 8/1/24), and Staff training on Resident Rights (dated 1/3/25) . On 6/28/25, at 9:24am, the Department and Memory Care Director (S2) toured the facility inside and out. The Department conducted 5 staff interviews (S1-S5), Executive Director (A1), and 6 Residents (R2-R7). The investigation revealed the following: Allegation: Facility staff is insufficient to meet resident's needs The complaint alleges that “the facility is trying to save money, and they are short staffed.” On 6/25/25 at 12:26p via telephone, the Department interviewed the Executive Director (A1) who denied allegation and stated that she has only been working at the facility a little over a month, she is certain that the facility has sufficient staff to meet residents’ needs. On 6/28/25 between 10:00am and 12:30pm, the Department interviewed 5 staff (Staff #1-5) regarding the allegation; 4 out of 5 staff denied the allegation and reported that there is enough staff to meet the needs of the residents. On 6/28/25, between 1:30pm and 3:00pm, the Department interviewed 6 Residents (Residents #2-7). R1 no longer lives at the facility. Of the 6 Residents interviewed, 5 out of 6 denied the allegation. 5 out of 6 stated that their needs are taken care of and that they feel that there are enough staff to meet their needs. On 6/28/25, The Department observed sufficient staff present at time of visit. On 6/27/25, The Department obtained, reviewed, and evaluated staff schedules and resident roster (current and week of incident) and found that sufficient staffing is maintained at the facility to meet the residents’ needs. Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occ ur, therefore the allegation is UNSUBSTANTIATED . Page 2 of 5 Allegation: Facility staff are not assisting resident with toileting needs in a timely manner The complaint alleges that when R1 tells the staff that R1 “has to use the restroom,” the staff takes longer to respond. On 6/25/25 at 12:26p via telephone, the Department interviewed the Executive Director (A1) who denied the allegation and stated that staff are not supposed to take more than 10 minutes to respond to a resident who calls for assistance. A1 further stated the staff are aware of the policy of responding to residents in a timely manner when they call for assistance. On 6/28/25 between 10:00am and 12:30pm, the Department interviewed 5 staff (Staff #1-5) regarding the allegation; 5 out of 5 staff denied the allegation and reported whenever a resident calls for assistance they help. 5 out of 5 staff interviewed stated that they have never waited too long to assist residents when they call. 5 out of 5 staff stated that they are aware of the Emergency and call system monitoring policy. On 6/28/25 between 1:30pm and 3:30pm the Department interviewed 6 Residents (R2-R7) regarding the allegation. 5 out of 6 residents stated that staff assist them in a timely manner when they called for assistance. On 6/27/25 the Department obtained, reviewed, and evaluated the Emergency and call system monitoring policy (dated 8/1/24) which states in part that “It is expected that emergency calls are responded to timely,” and “upon move in the Executive Director or designee will provide all assisted living residents with training on the use of emergency call devises.” Page 3 of 5 Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Allegation: Resident sustained multiple falls while in care The complaint alleges that R1 was admitted to hospital due to a fall on 9/1/2021 and R1 allegedly has had multiple falls within the year. Additionally, it is alleged that R1’s medication and chronic condition is making R1 “feel faint” resulting in falls. On 6/27/2025 at 12:26p, the Department interview A1 who stated that R1 no longer lives in the facility and the facility doesn’t have any records pertaining to R1’s case due to the time frame that the facility is required to keep records (records are kept for 3 years) and this complaint is from 2021. However, during the initial complaint visit on 10/12 /21, the Department obtained copies of R1’s Service Plan (dated: 7/6/21), R1’s eMAR (for Aug 2021), Unusual Incident Report (UIR) dated 9/18/21 and 9/1/21. The Department reviewed the documents listed above which showed that R1 has had a couple falls during that time and the facility took appropriate steps to ensure that R1 was seen by a medical professional and followed up with R1’s primary care physician . It is unknown what was put in place for R1 specifically, due to the lack of information. The Department obtained and reviewed a copy of the facility’s fall policy (Dated 3/1/25), which includes: Fall risk reduction, environmental safety, and lift assistance Page 4 of 5 Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . There were no deficiencies cited during today's visit. Exit interview conducted, and copy of report provided to Executive Director Judith Pierfax. Page 5 of 5