complaint·December 18, 2025

(Continued from LIC9099) (Page 2 of 3) It was alleged that Resident #1 (R1) was charged for Level 1 care services from October 30, 2024, through February 2025, despite a cancellation request from R1’s Responsible Person. The Department records review revealed that on October 15, 2025, R1's Responsible Person was informed of a change in R1’s contracted services , effective October 13, 2025, to Level 1 care with bathing assistance up to 3(three) times weekly, as documented in the Resident Change Form. R1 was assessed for a change in condition, and the Change Form was presented to R1's Responsible Person. Staff interviews confirmed that although the Responsible Person disputed the charges and did not pay for Level 1 care from October 2024 through May 2025, services continued per the care plan to support R1’s health and safety. Interviews with other residents indicated similar services were consistently provided. It was further alleged that meals were delivered late, cold, incomplete, and did not meet R1's preferences. Department interviews revealed the facility had implemented changes to reduce tray service and promote communal dining. Resident interviews revealed satisfaction with meal quality and timeliness, including room service, and understood trays were delivered after dining room service concluded. The department interviews with the Food Service Director revealed the availability of dietary accommodations, including alternative menus and individualized counseling. The department staff interviews and records further revealed that missed meals were tracked, and efforts were made to ensure proper food temperature. The Resident Handbook outlined structured mealtimes and flexible room service policies. The department observations confirmed clean kitchen conditions, posted dietary notes, and active meal preparation. It was further alleged that staff failed to assist R1 after a courtyard fall and missed scheduled showers. No documentation of the fall was found, and R1 was unavailable for interview, having moved out without providing contact information. The direct staff witness was also unavailable. Regarding missed showers: The department interviewed with staff revealed R1 was scheduled for twice-weekly showers and offered additional assistance. However, R1’s shower/grooming logs were unavailable. The department records reviews reveal that for current residents, showed consistent service provision, and staff were observed actively assisting residents during the Department’s visit. Based on available evidence, the Department determined the allegation was not substantiated. (Continued on LIC9099C) (Continued form LIC9099C) (Page 3 of 3) I t was further alleged that the facility is in disrepair.  More specifically, R1’s toilet overflowed on January 23, 2025, flooding the room without proper sanitization; multiple leaks were reported; and a courtyard crack caused a fall. Depart ment interviews and records review revealed the flooding was promptly addressed by maintenance, and a SERVPRO inspection found no elevated moisture or microbial growth. R1 was temporarily relocated during repairs and ventilation. The department interviewed resident and revealed residents consistently reported that maintenance issues, when brought to the attention of staff, are addressed promptly and effectively Department observations during multiple site visits confirmed clean, well maintained common areas and no evidence of major cracks in community pathways. 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.