complaint·May 30, 2023

There are no records of when the missing window blinds were reported by the residents. There is only record of when it was fixed. Records show it was fixed on 4/14/23. There is no record of the amount of time that passed between when the item was reported broken and when it was fixed. As of today 5/30/23, at 11:15am, LPA observed the window blinds were replaced. It is alleged that staff do not ensure the facility is in good repair. During the staff interviews it was reveled that the facility has a system for work orders to be processed and addressed. At this time and for the past 6 months or more, the maintenance department is comprised of one (1) staff member. The facility maintains a Service Log which is meant to keep track of work orders being reported and when they are completed. At this time, the facility does not keep track of the progress of those work orders. For example, maybe a task requires a special part or tool in order to be fixed or addressed, there is no record of what has been done or what is needed in order to be fixed. Because progress of these work orders are not being tracked, there is only 1 maintenance staff member and there is a high volume of residents in care it is likely that some work orders do not get fixed in a timely manner. We have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with and provided to the facility representative. Please see LIC 9099D. We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.