Complaint·June 8, 2026

None of the residents expressed concerns regarding bathing services. During facility visits conducted on 02/05/2026, 03/10/2026, and 04/20/2026, LPA Lee toured the facility and resident bedrooms and did not observe any odors of incontinence or other unpleasant smells. During the visit on 04/20/2026, residents observed in the lobby, outdoor patio, and activity room appeared clean and well-groomed. The nine residents interviewed also appeared clean and appropriately groomed. A review of the facility's shower schedule indicated that residents are scheduled to receive showers at least two to three times per week and additionally as needed. Furthermore, LPA Lee reviewed shower logs for 10 residents from January 2026 through March 2026. The records showed that residents received an average of eight to twelve showers per month. Based on interviews, observations, and records reviewed, LPA Lee was unable to corroborate the allegation that staff do not meet residents' bathing needs. It was alleged that staff do not respond timely to residents' call lights. The investigation included interviews with staff and residents, observations, and a review of facility records. Based on the investigation, it was learned that the facility utilizes a call light system in each resident's room. Residents activate the system by pulling a cord, which illuminates a light outside the resident's room to alert staff to ensure that assistance is needed. The activation also appears on call panels located in the front lobby and at the nurse station. Staff then communicate via walkie-talkie with Resident Aides (RAs) regarding the resident's location and need assistance. LPA Lee interviewed five out of five staff members, all of whom denied the allegation and stated that resident call lights are responded to promptly. Additionally, six out of nine residents interviewed reported that staff generally respond to their call lights within five to ten minutes and expressed no concerns regarding delayed staff response times. During a facility visit conducted on 04/20/2026, LPA Lee observed and tested nine call light response events. Staff response times ranged from one to seven minutes, with an average response time of approximately three minutes. A review of facility records revealed that call light response logs were not available. The Administrator stated that the facility recently implemented a new call light system that remains in a trial phase and has not yet gone live; therefore, historical call log reports were unavailable at the time of the investigation. Based on interviews, observations, and records reviewed, LPA Lee was unable to corroborate the allegation that staff do not respond timely to residents' call lights. CONTINUED LIC 9099-C It was alleged that staff yell at residents and that staff behavior poses a risk to residents in care. The investigation included interviews with staff and residents, as well as facility observations. LPA Lee interviewed 5 out of 5 staff members, all of whom denied the allegation. Staff stated that they do not yell at residents and have not observed other staff members yelling at or behaving inappropriately toward residents. LPA Lee also interviewed 8 out of 9 residents, all of whom denied being yelled at by facility staff and being treated inappropriately. Residents reported that staff are “nice” and that they had no concerns regarding staff behavior. During facility visits conducted on 02/05/2026, 03/10/2026, and 04/20/2026, LPA Lee toured the facility and resident bedrooms and did not observe any staff yelling at residents or engaging in behavior that would place residents at risk. Based on interviews conducted and observations made during the investigation, LPA Lee was unable to corroborate the allegation that staff yell at residents and that staff behavior poses a risk to residents in care. It was alleged that facility staff do not provide adequate supervision to residents. The investigation included interviews with staff and residents, as well as facility observations. LPA Lee interviewed 5 out of 5 staff members, all of whom denied the allegation. Staff stated that personal cell phone use is prohibited during working hours. Staff further explained that Resident Aides (RAs), medication technicians, and management are issued facility cell phones that are used as walkie-talkies to communicate regarding resident needs, call lights, and other operational matters. LPA Lee also interviewed 8 out of 9 residents, all of whom denied the allegation and reported no concerns regarding staff supervision or staff using phones while providing care. During the facility visit conducted on 04/20/2026, LPA Lee observed Resident Aides using facility-issued phones to communicate with other staff members regarding resident call lights activated in Rooms 110 and 115. LPA Lee did not observe staff using personal cell phones while on duty, nor were any residents observed to be neglected or unsupervised as a result of staff phone use. Based on interviews conducted and observations made during the investigation, LPA Lee was unable to corroborate the allegation that facility staff do not provide adequate supervision to residents. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.