Complaint·September 25, 2025

In an interview, R1 stated that R1 has no concerns with R1’s toileting needs and added that staff 1(S1) does a very good job assisting with toileting needs. Additionally, five out of five facility staff interviewed denied the allegation that residents’ toileting needs are not being met. Interviews were also conducted with two outside agencies responsible for residents under their care. Both agencies reported no concerns regarding the toileting care provided to the residents. Based on the records reviewed and interviews conducted, there is insufficient evidence to determine whether the alleged violations occurred. It was alleged that staff yelled at residents in care. This investigation involved interviews with facility staff, residents, and two outside agencies. LPA Lee interviewed 5 out of 5 residents , all of whom stated they had not experienced or witnessed facility staff yelling at them or other residents. In a separate interview, Resident 2 (R2) also denied that s taff 2 (S2) yelled at them. R2 further expressed that R2 was not happy that a complaint had been filed which included R2 in the allegations. LPA Lee also interviewed 5 f acility staff members , all of whom denied the allegation and stated they had not yelled at residents , nor witnessed any other staff yelling at residents. In addition, t wo outside agencies were interviewed. Both stated they had never witnessed staff yelling at residents and described the staff as kind and respectful. Based on the interviews conducted, there is insufficient evidence to determine whether the alleged violations occurred. It was alleged that staff are not meeting residents dietary needs. This investigation included observations and interviews with facility staff, residents, and two outside agencies. During two facility visits conducted on 07/07/2025 and 09/04/2025 , LPA Lee toured the facility kitchen and observed that the facility had sufficient supply of food , including t wo days’ worth of perishable and seven days’ worth of non-perishable items. LPA Lee also observed residents being served adequate portions of food during both breakfast and lunch. Interviews were conducted with 5 out of 5 residents , all of whom stated they receive enough food and have no concerns regarding their dietary needs. Additionally, Resident 2 (R2) expressed that R2 was not happy that a complaint had been filed which included them in the allegations. LPA Lee also interviewed 5 out of 5 facility staff , all of whom denied the allegation that residents’ dietary needs are not met and that residents are allowed to ask for second during mealtime. Furthermore, two outside agencies confirmed that the residents under their care have not reported any concerns regarding the adequacy of food or dietary accommodation. CONTINUED LIC 9099-C During the course of the investigation, LPA Lee was provided with photographic documentation from the facility. It was learned that photos are taken of each meal, breakfast, lunch, and dinner by kitchen staff and shared in the facility's internal chat group for documentation purposes. These photos demonstrate that meals are provided in accordance with residents’ dietary needs and residents are given sufficient portion during mealtimes. Based on observations, record reviews, and interviews conducted, there is insufficient evidence t o determine whether the alleged violations occurred. It was alleged that staff are not seeking timely medical care for residents . This investigation included a review of records and interviews with facility staff, residents, and two outside agencies. Based on the records reviewed, the facility currently has t wo residents on hospice care, and their wound care is being managed by hospice nurses. Additionally, documentation of two-hour rounding checks confirms that residents' wounds are being monitored regularly by facility staff and communicated to their hospice nurses. LPA Lee interviewed 5 out of 5 residents, all of whom expressed no concerns r egarding staff failing to seek timely medical care. Interviews with 5 facility staf f revealed that residents with wounds are under hospice care and that their conditions are monitored jointly by facility staff and hospice nurses. Staff also stated that all relevant care information is communicated directly to the hospice team. Two outside agencies were also interviewed. Both confirmed they had no concerns regarding the timeliness of medical care provided by the facility to the residents under their supervision. Based on the records reviewed and interviews conducted, there is i nsufficient evidence to determine whether the alleged violations occurred. 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. An exit interview was conducted, and a copy of this report were provided to the facility at the end of this visit