complaint·February 24, 2026

Second Allegation: Facility staff yelled at residents. Seven(7) out of Seven (7) residents stated that facility staff have never yelled at the residents and are always helpful and kind to them. Five (5) out of Five (5) facility staff stated that staff never yelled at residents, they do speak loud sometime due to some residents hearing issues but never yelled at the residents in care. Third Allegation: Facility staff did not meet residents' incontinence care needs. Seven(7) out of Seven (7) residents stated that facility staff has always met residents’ incontinent care needs. Five (5) out of Five (5) facility staff stated that staff did meet residents' incontinence care needs and assist residents in daily activities of living. Fourth Allegation: Facility staff did not ensure residents had clean bed sheets. Seven(7) out of Seven (7) residents stated that facility staff always ensure that residents have clean bed sheets . Five (5) out of Five (5) facility staff stated that staff did ensure that residents have clean bed sheets and linen and change it weekly or as needed. Fifth Allegation: Resident sustained an unexplained injury in care. Seven(7) out of Seven (7) residents interviewed reported having no knowledge of the specific individual who sustained an unexplained injury while under the care of staff. Five (5) out of Five (5) facility staff stated that residents are being looked after well and staff contact emergency services whenever a resident is injured or requires immediate assistance. Residents expressed a consistent belief in the facility’s safety procedures, noting that staff members reliably contact emergency services whenever a resident is injured or requires immediate assistance. Sixth Allegation: Resident not accorded dignity in personal relationships with staff. Seven(7) out of Seven (7) reported that facility staff consistently maintain high professional standards. These residents characterized their interactions with the staff as being defined by dignity, respect, and a genuine commitment to quality care. Five (5) out of Five (5) facility staff stated that it never happened that any resident not accorded dignity in personal relationships with staff. Seventh Allegation: Facility staff did not ensure residents were regularly observed for changes in functioning. Seven(7) out of Seven (7) residents stated that according to a recent report, 80% of residents confirmed that facility staff maintain consistent oversight regarding their well-being. The residents stated that employees effectively monitor them for any changes in physical or mental functioning, as well as shifts in their overall medical conditions. A significant majority of residents feel actively monitored. Staff are recognized for identifying fluctuations in resident health. Five (5) out of Five (5) facility staff stated facility staff always ensure residents were regularly observed for changes in functioning. Eighth Allegation: Facility did not meet night supervision requirements. Seven(7) out of Seven (7) residents stated that facility staff do meet night supervision requirements and Staff stated that there are enough staff for NOC Shift and there is one staff who is on call and Staff check on residents during the night. LPA reviewed records which shows there are enough staff for the night supervision and to take care of the residents at night shift. Based on the information obtained there is not enough evidence that staff are not following COVID protocol, staff are not meeting the needs of COVID Positive residents, residents are not being served meals in a timely manner due insufficient staffing, residents are not being assisted with feeding in a timely manor due to insufficient staffing, residents are not being assisted with toileting in a timely manner. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted where this report LIC9099 was discussed, and a copy of the report was provided to the Facility Executive Director Ashley Willett at the conclusion of the visit.