complaint·January 27, 2026

On the allegation: Staff leave residents unattended for extended periods of time. LPA De Leon reviewed call button logs for the 7 randomly chosen residents at the facility for a 7-day period from June 1, 2025-June 7, 2025, which revealed 3 out of 7 residents reviewed had call button logs over 15 minutes to a maximum of 96 minutes. One Resident had 9 calls over 15 minutes, 1 at 15 minutes, 2 at 16 minutes, 1 at 18 minutes, 1 at 20 minutes, 1 at 21 minutes, 1 at 22 minutes, 1 at 25 minutes and 1 at 48 minutes. The next resident had 1 call at 37 minutes, another Resident had 7 calls with 1 at 15 minutes, 1 at 16 minutes, 1 at 17 minutes, 1 at 19 minutes, 1 at 40 minutes, 1 at 50 minutes and 1 at 96 minutes. Staff interviews revealed call buttons are usually answered in under 10 minutes if the facility is fully staffed. Staff stated residents use the call buttons for non-emergent matters at times. LPA reviewed records and there is no way for staff to tell if the next call button press is non-emergent or an emergency matter unless staff go to the location and check on the resident. Staff interviews revealed the facility was short staffed for periods of time during 2024-2025 and during those times when the facility was short staffed it took longer to answer the calls while doing regular duties assigned with resident’s showers, dressing, transferring and assistance. Staff stated that when they are with a resident, they must finish taking care of the resident before they can move on to the next call or the next duty assigned. Based on the evidence this allegation is Substantiated at this time. On the allegation: Staff do not respond to requests for assistance from residents. LPA De Leon reviewed call button logs for the 7 randomly chosen residents at the facility for a 7-day period from June 1, 2025-June 7, 2025, which revealed 3 out of 7 residents reviewed had call button logs over 15 minutes to a maximum of 96 minutes. One Resident had 9 calls over 15 minutes, 1 at 15 minutes, 2 at 16 minutes, 1 at 18 minutes, 1 at 20 minutes, 1 at 21 minutes, 1 at 22 minutes, 1 at 25 minutes and 1 at 48 minutes. The next resident had 1 call at 37 minutes, another Resident had 7 calls with 1 at 15 minutes, 1 at 16 minutes, 1 at 17 minutes, 1 at 19 minutes, 1 at 40 minutes, 1 at 50 minutes and 1 at 96 minutes. LPA reviewed 7 randomly chosen resident care plans which revealed six out of seven (6/7) residents had care plans with additional services needed. Continued 9099-C Care Plan 1- included Bathing maximum assistance 2 x per week, Dressing maximum assistance daily in the am and pm, Oral Care maximum assistance daily, Hearing moderate assistance with devices from Med-Tech daily am and pm, Toileting maximum assistance several times daily, Meals moderate assistance cutting, preparing and prompting, Engagement minimal assistance needed, Housekeeping services 1X per week. Care Plan 2- included Bathing is now done by Hospice Agency staff, Dressing maximum assistance reminders and preparing items, Toileting maximum assistance stand by assist as needed daily, Transfers moderate assistance standby assist when needed daily, Mobility maximum assistance escort to meals with walker and reminders, Medication Management maximum assistance med pass 2x a day, Coordination of Care moderate assistance with hospice agency, Housekeeping services 1x per week with daily trash pickup. Care Plan 3- included Cognition, Behavioral Expression and Communication minimum assistance prompting and observation, Bathing maximum assistance 1x per week, Mobility minimum assistance walker with daily observation, Care Plan 4- included Bathing is done by Hospice agency, Dressing is maximum assistance daily am and pm, Toileting maximum assistance daily when needed, Transfer maximum assistance daily, Mobility maximum assistance daily, Meals minimum assistance daily reminders, Engagement minimum assistance reminders and observation, Medication Maximum Assistance needed. Housekeeping services 1X per week. Care Plan 5-included Mobility maximum assistance for escorts, walker and wheelchair, Engagement minimum assistance for need and observation, housekeeping services 1X per week. Care Plan 6-included Bathing maximum assistance 1 staff 2 x a week, Dressing maximum assistance, Toileting maximum assistance, Mobility maximum assistance with a walker, Medication maximum assistance pass up to 4 or more times per day by a medication technician (Med-tech), Coordination with outside agency moderate assistance Home Health, Housekeeping services 1X per week and Trash assistance daily 7 x a week. Care Plan 7-Resident does not have additional services and is independent of the care plan. Care staff are assigned residents to showers, dressing, and transfers daily and in addition to residents pressing their pendants for help daily. Records reviewed show the residents waiting 15 plus minutes for help with daily Assistance with Assistance with Daily Living (ADL) and on days where the staff are short-handed the wait times can be even longer. Staff interview revealed staff do respond to residents for assistance but at times residents wait so long the resident does the tasks themselves, which can be a safety risk for some. Continued 9099-C Timely assistance was not provided to residents in care based on record review and interviews this allegation is Substantiated at this time. This allegation is the same deficiency as the one cited on the previous allegation and will not be cited due to duplication of the same deficiency. On the allegation: Resident's room is odiferous. LPA De Leon conducted a tour of resident 1’s (R1’s) room and once LPA entered the doorway the room had a strong urine odor. LPA took photos of R1’s bed and restroom which both needed cleaning and sanitizing. Staff interviews revealed 5 out of 7 staff stated R1’s room had a heavy urine odor. Witness interview revealed resident room had a heavy smell of urine all the time and an odor of feces at times when the bedding had not been changed. Witness interview stated it had been reported to the care staff and directors and nothing was done about it. R1’s care plan revealed that R1 could not clean R1’s own room and restroom and this was to be completed by housekeeping staff. Staff stated that R1’s room was brought to the attention of housekeeping and directors, and the care plan was not updated to accommodate additional services needed to maintain odor, cleanliness, sanitation and disinfection. R1 moved out of the facility, and according to interviews it took several cleanings to get the room back into rentable condition, therefore this allegation is Substantiated at this time. On the allegation: Staff do not provide activities for residents. LPA interviewed staff members which revealed activities program director quit, and the new activity staff or director was not hired for several months leaving activities short staffed for a period of 1-3 months, some staff helped run a few activities during this period, but several activities were cancelled. The activities calendar was not followed during this time. Resident interviews revealed residents would attend the activity posted on the calendar and no staff would show up to run the activity. Several residents said they no longer attend activities or certain activities are not the same as they used to be and residents do not care to attend any longer. Witnesses interviewed revealed staff weren't providing the residents with activities. A witness said the facility had bingo at witness request, but the facility expected resident family members to call out the bingo numbers due to not having enough staff to run the activities. Based on the evidence this allegation is Substantiated at this time. Continued 9099-C On the allegation: Staff do not ensure that residents receive their mail. LPA observed packages being delivered to the facility, LPA interviewed the front desk staff to see what the procedure was for resident’s package delivery. Staff stated the packages were delivered to the front desk, left on the counter area and when any staff member had time the packages were picked up by staff at the front desk and delivered to the resident’s room. The staff stated they do not log or keep any information regarding delivery of packages received on file or any information about the staff that delivered the packages to the room. According to Witnesses packages were shown as delivered by the carrier but not received by the residents and it was unknown where the packages were at in the facility. LPA recommended a log to be kept so staff could be aware of what was delivered by the carrier and who delivered the package to the residents’ room. The front desk keeps a log of package deliveries now. Based on the lack of resident’s package not getting delivered to the resident’s room, the package not being available for pick up at the front desk and the resident not getting the package after delivery by the carrier to the facility. The facility failed to safeguard the residents mailed packages therefore this allegation is Substantiated at this time. On the allegations: Staff do not ensure that residents’ bedding is sanitary. LPA De Leon conducted a tour of resident 1’s (R1’s) room and once LPA entered the doorway the room had a strong urine odor. LPA took photos of R1’s bed and restroom which both needed cleaning and sanitizing. Staff interviews revealed 5 out of 7 staff stated R1’s room had a heavy urine odor and in need of cleaning. Witnesses interview revealed resident room had a heavy smell of urine all the time and an odor of feces at times when the bedding had not been changed. Witnesses interview stated it had been reported to the care staff and directors and nothing was done about it. R1’s care plan revealed that R1 could not clean R1’s own room and restroom and this was to be completed by housekeeping staff. Staff stated that R1’s room was brought to the attention of housekeeping staff and directors, and the care plan was not updated to accommodate additional services needed to maintain odor, cleanliness, sanitation and disinfection. R1’s linens were only being changed weekly or longer if staff were shorthanded. R1’s linens were not changed after being soiled with urine and feces therefore this allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.