complaint·October 20, 2025

emergencies, including the use of on-call staff and agency personnel when necessary. The facility maintains documentation of initial and ongoing training, including topics such as resident rights, supervision, and behavioral management. Staff interviewed demonstrated knowledge of their responsibilities and resident care needs. LPA interviewed three (3) residents, none of whom reported feeling unsafe or unsupervised. Residents stated that staff are generally available and responsive. No residents reported being bothered by others due to a lack of supervision. LPA interviewed three (2) outside sources, none of whom reported feeling unsafe or unsupervised. Residents stated that staff are generally available and responsive. No outside sources reported their loved ones being bothered by others due to a lack of supervision. During the visit, LPA observed staff actively supervising residents in common areas. No incidents of resident-to-resident conflict were observed, and residents interviewed did not report concerns about supervision. On 12/6/23, it was alleged that staff are not assisting residents with eating. LPA interviewed [#] staff members, all of whom stated that residents who require assistance with eating are identified in their care plans and are assisted during meals. Staff demonstrated knowledge of residents’ dietary needs and assistance levels. Training records reviewed confirmed that staff received instruction on providing assistance with activities of daily living, including eating, as required LPA interviewed three (3) residents, including those identified as needing assistance with eating. Residents reported that staff are available during meals and provide help when needed. No residents expressed concerns about being neglected or not receiving assistance during mealtimes. LPA interviewed two (2) outside sources that reported there are staff available during meals and provide help when needed. No outside sources expressed concerns about their loved ones not receiving assistance during meal times. LPA observed staff assisting residents in a timely and respectful manner. Residents were seated comfortably, and staff were seen offering verbal prompts, physical assistance, and monitoring residents as appropriate. No concerns were noted during the observation period. The Department has investigated a complaint with the above allegation. The Department has found that although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted with the Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.