Complaint·February 4, 2025

Based on observations made on 11/27/24 and 12/24/24, LPA Lee did not find any evidence that the facility staff was providing an unsafe environment for residents in care. During the investigation, it was learned that the facility had accommodated resident 1 (R1) by installing a new doorknob at R1’s request. Furthermore, the facility made an effort to accommodate (R1) by offering a move to the front of the main building. However, R1 would need to share the room with (R2), as R2’s room was the only available space. R1 declined the offer, expressing a preference for a private room, similar to the one R1 is currently occupying in the Terrace Hall. It was alleged that the facility does not provide a comfortable environment and comfortable temperature for residents. The investigation included interviews with staff, residents, and outside agency as well as on site observations. Based on the interviews, 6 out of 7 residents expressed no concerns regarding the comfort of the environment or temperature in the facility. In fact, these residents stated they were content living in the facility. 4 facility staff members denied the allegations, stating that they communicate regularly regarding residents' needs. Staff also reported they frequently accommodate (R1) by providing room service such as ice, towels, meals, and a specific butter R1 requested. Additionally, staff stated that R1 is not charged for room delivery and that they make efforts to ensure R1 feels comfortable in the facility. Based on R1's admission agreement, there is no contract stating that the facility will provide room delivery, and R1 is not being charged for room delivery. Staff further denied allegation of uncomfortable temperatures, stating that the temperature is typically set between 70°F and 78°F. The outside agency also stated that the facility makes efforts to accommodate R1. During an observation on 11/27/24, LPA Lee observed residents appeared comfortable. A tour of the facility showed that the temperature in the main building downstairs was 72°F, while the temperature in the wall building measured 74°F. The temperature in the Terrace Hall downstairs was 78°F, and upstairs it was 72°F. The temperature in R1’s room was recorded at 69°F which is within the regulation of 68* F to 85* F. LPA Lee observed multiple residents room measured at 78* F. LPA Lee also confirmed there was no feces or potting soil in any of the resident bathroom toilets or sinks. During a follow-up visit on 12/24/24, LPA Lee observed 12 residents in the dining room and 4 in a smaller dining room, all having lunch and appearing comfortable. R1's room was measured at 73°F, and the bathrooms in the Terrace Hall were clean, sanitary, and free of feces or potting soil. It was alleged that the facility does not have sufficient number of bathrooms to meet residents' needs and that the facility’s shower is in disrepair. Continued LIC 9099-C The investigation included interviews with staff and residents. According to interviews, 6 out of 7 residents reported no concerns regarding the number of bathrooms and the shower not in good repair. 4 facility staff members denied the allegations, confirming that there are a total of 7 bathrooms in the facility. During a visit on 11/27/24, LPA Lee observed that the facility does indeed have 7 bathrooms. The main building has 2 bathrooms upstairs and 1 downstairs. The Terrace Hall has 2 bathrooms downstairs and 2 bathrooms upstairs. Both facility visits on 11/27/24 and 12/24/24, LPA Lee also observed that all showers in the facility were in good repair. Based on statements obtained, records review and observations during the investigation process, LPA was unable to corroborate the allegations. 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.