Complaint·June 19, 2025

There are two boilers that supply a large hot water tank and from there the hot water is delivered to the kitchen and through mixers to all other areas of the facility. LPA interviews revealed on 5/1/2025 a plumber repaired a leak in one of the boilers, there was not a hot water issue at this time, the plumber recommended the boiler be replaced but they do not work on boilers. Vice President of Operations Lisa Hulse contacted Wick Boiler Service, Inc to schedule a maintenance visit on 6/2/2025 and they recommended rebuilding the boilers at that visit. On 6/16/2025 Administrator Liza Hix was notified by staff there was no hot water at around 8:00am, she contacted Wick Boilers via text message at 8:21am and they arrived at the facility the same day at around 11:00am. LPA observed during the previous visit to the facility for this complaint on 6/18/2025 a boiler company was working on the boilers. LPA interviews with staff revealed there have been a couple of occasions over the last year or two where the water was not hot enough to shower residents, the issue was resolved within a couple of hours, and staff were instructed to schedule the showers later in their shift. LPA interviews revealed the showers were completed by staff and residents have not had to take cold showers. As of 6/19/2025 the boilers have been fixed and the facility is working to ensure the hot water temperature is within regulation. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. On the allegation: Staff do not ensure that resident's needs are met. It was alleged that the facility is understaffed, resulting in residents not receiving incontinence care regularly and residents who go out to the secured patio are alone and fall frequently. LPA interviews with staff revealed 6 of 7 staff feel the facility is staffed to meet the residents needs, there are occasional call offs, and the facility covers the staff call offs. LPA interviews also revealed the staff are not aware of any incontinence issues not being met and they are expected to check the incontinent residents ever 1-2 hours or more often for residents who need. LPA interviews revealed that staff are expected to check the secured patio every 30 minutes – 1 hour and the majority of staff interviewed believe this is being done. LPA noted during file review that three residents have fallen in the secure patio area in the last three months, the facility called 911 and submitted incident reports to Licensing. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. On the allegation: Staff do not ensure that the facility is sanitized. It was alleged that due to the faucets not delivering hot water the kitchen could not be sanitized. LPA interviews with kitchen staff revealed the kitchen wash all kitchen utensils and dishware in a dish sanitizer that utilizes a disinfectant agent and when the sanitizer is not functioning, they have a backup sink with three basins and sanitizing chemical to perform the “three sink sanitization method.” LPA interviews showed that during this week’s hot water issues the kitchen staff were able to follow sanitizing protocols or wait for the hot water supply to be restored between maintenance. LPA observed the kitchen to be clean, organized and free of debris. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, no citation was given at this time and report was provided.