complaint·January 4, 2024

licensee has adequate supplies of PPE and essential cleaning supplies to care for persons in care, and licensee has adequate access to COVID-19 testing, and require visitors to wear face coverings. The pin further states that if all conditions are met, indoor visitation at the facility is permitted”. Upon records review the facility did have positive COVID-19 cases and were all clear as of 12/25/20, however were still waiting for two consecutive negative tests. A facility welfare check (check on the facility after having positive COVID-19 cases) was conducted by the department on 2/23/21, and Executive Director Cheree reported that all restrictions had been lifted within the community, as there were no positive cases and testing was completed with negative results as of 2/8/21. Interviews conducted with residents revealed that the only time visits were put on hold is when there was a sickness such as COVID in the building. Based on observations, interviews and records review the allegation is UNSUBSTANTIATED. Resident is not allowed to leave the facility while in care Allegation: Resident is not allowed to leave the facility while in care. Per an interview conducted with Cheree, ED during the initial complaint visit residents are allowed to leave the facility and upon their return, they are screened for COVID symptoms, their temperature is taken, they are asked to sanitize and sign back in. LPA conducted interviews with residents and stated that the only time they did not leave the facility was if there was a sickness going around such as COVID. Residents further stated that they were able to come and go as they had their private patios. Residents stated that if they left that had a mask that was provided and worn. Residents understood the reason for anything that was put into place. Based on interviews the allegation is UNSUBSTANTIATED. Allegation: Staff does not ensure residents are properly fed while in care Cheree was not aware of any complaints with the food. Cheree stated that so much has changed since the complaint has come in and that the facility has a new Director of Culinary. LPA conducted a walk thru of the facility's kitchen which was observed to be clean and clutter free. The facility food supply was observed to meet the expectation of having a 2-day supply of perishable and a 7-day supply of nonperishable food items. The fresh fruits and vegetables were observed to not have any signs of being rotten. The facility serves 3 meals (Breakfast, lunch and dinner). Per the observed menus, Breakfast options are to have a light option (cold cereal, pastries) or hearty option (eggs, waffle or breakfast burrito), Lunch lighter fare (soup, salad) or from the grill (cheeseburger, hot dogs, chicken tenders etc.) For dinner two (2) entrée options examples include soup and chicken or soup and Pork Marsala. In addition, LPA observed in the and Bistro walk up area grab and go refrigerators that contained assorted beverages, Jell-o. Per interviews conducted with residents revealed that residents are fed all three (3) meals and snacks are available. In addition residents provided that there are specified hours that residents can go and get whatever they please from 7am-7pm. The facility does have all day dining. Based on observations, interviews and records review the allegation is UNSUBSTANTIATED. Allegation: Staff threatens a resident with eviction while in care LPA conducted an interview with ED Cheree Escandel whom stated that she could not recall Resident #1 (R1) being issued an eviction notice or being threatened with eviction. LPA conducted a review of R1s file and there was an eviction notice issued on 09/19/19 by the previous facility Administrator. The notice was issued due to R1 having failed to follow the house rules such as the smoking policy, guest accommodations, guest meals, and guest visitor log. R1s room had the smell of marijuana coming from their room on multiple occasions, the guest(s) were believed to be living at the facility, R1 was also ordering food for two people, when the guest meals are available for a fee. Lastly R1 would have visitors that were not signing in and out. The eviction notice was rescinded on an unknown date. LPA conducted interviews with residents which revealed that they had not been threatened with eviction since living at the facility. Based on insufficient evidence the allegation of staff threatens a resident with eviction while in care in UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this report was provided to Cheree Escandel, Executive Director.