complaint·July 21, 2025

(Continued from 9099) Resident #1 (R1) 's physician report dated July 22, 2023, indicates that R1 uses a wheelchair for mobility and exhibits wandering behavior. However, a review of records and department observations confirmed that R1 can self-propel their wheelchair and navigate the facility grounds independently. Records review of an outside medical provider revealed that the licensee staff appropriately notified R1's medical provider of a change of condition. The medical provider responded for evaluation and determined that a hospital visit was unnecessary. Interviews with staff indicated that staffing was based on residents' acuity levels. Medication Technicians (Med Techs) on each shift were an extra person to assist when needed. Additionally, the facility used an Agency/Registry staff to help assist in the recommended staffing numbers. Regarding the allegation, the facility had no food service director. More specifically, there is no dietary person at the facility, and they do not know if there is emergency food and water as per the regulations. Annual inspections conducted by the department reveal that there are emergency food and water supplies at the facility. Interviews and records review confirm that the Licensee employs one designated person responsible for food planning, preparation, and service. Regarding the allegation, the staff did not meet the residents' laundry needs. More specifically, clothes were not cleaned on time. Interviews with staff reveal that staff usually wash and fold laundry on the NOC shift. Interviews with staff also reveal that they are aware of the laundry service needs and are hiring additional staff. However, the department did not observe residents wearing soiled clothing. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Jonathan Wheeler , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A reply E-mail or read receipt confirmation was requested from Executive Director Wheeler upon receipt of documents