complaint·December 15, 2025

(Continued from LIC9099) Regarding the allegations of Inadequate staffing resulting in unmet resident care needs, including bathing, toileting, and meal service. The Department interviews revealed that residents were generally satisfied with the care provided. They reported receiving timely assistance with bathing, toileting, grooming, and meals. Staff acknowledged that some residents occasionally refused care services, such as bathing or grooming, but stated that efforts were made to re-approach and provide assistance. Regarding meal service, staff confirmed that room trays were delivered after dining room service concluded, in accordance with facility policy. One outside source expressed concern about staffing levels and their potential impact on both personal care and meal delivery. However, they also noted that resident refusal contributed to missed services. The Department reviewed facility records, which showed a reduction in room tray service following administrative efforts to encourage communal dining and manage service demand. No evidence was found of systemic delays or failures in providing care or meals. Regarding the allegation that the delayed response to resident call buttons led to unmet care. Staff reported that the facility transitioned to a new call system in early 2025, which allows staff to receive alerts and document their response times. Due to the timing of the transition, call button logs were not available for the review period. However, staffing documentation confirmed consistent coverage.  Resident interviews did not reveal concerns regarding call button response times. Residents reported that staff responded when needed and were generally attentive. The Department conducted an in-depth review of facility documentation, including staffing schedules, timekeeping records, hygiene schedules, and care logs. The review confirmed that staff were scheduled to provide care services consistently during the period in question. Documentation showed that residents were scheduled for regular bathing and grooming services, and staff recorded completed care, refusals, and follow-up attempts. Observations made during the visit confirmed that residents appeared clean, well-groomed, and were receiving assistance. The department observations confirmed that meals were being served in a timely and organized manner. LPA observed staff responding to residents during the visit without delay. Based on interviews, and records review and department observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director via email. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to both via E-mail.