complaint·January 27, 2026

On the allegation: The facility does not respond to residents' calls for assistance in a timely manner due to insufficient staffing. 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. 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. Continued 9099-C 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. Witnesses interviewed revealed resident wait times for assistance with ADL’s in much longer than the 10 minutes the facility says it takes and dining times are much longer when the facility is short staffed on that day. 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 Complaint #29-AS-20250604132416 during the same period therefore it will not be duplicated on this complaint. On the allegation: The facility does not ensure sufficient staff in the dining room to serve meals timely. LPA conducted interviews with Caregivers which revealed they had to help in the dining room. Staff stated the dining room has been short staffed, and the facility was using caregivers to help take orders and get food if there were not enough kitchen staff to do so, the facility stopped using care staff for sanitary purposes. The waiting times for taking orders and getting food were longer at times when there were not enough staff. A staff member stated one of the housekeeping staff had to take off work for a while and some of the regular cleaning schedules were not kept up during a period of 1-2 weeks in resident apartments and in the common areas due to not having enough staff to help clean. A staff member said in 09/2025 the facility had hired enough kitchen staff to be fully staffed with servers and the facility asked a server to cover the vacant housekeeper position. LPA interviewed 7 out of 7 Residents which revealed the wait times could be 15-40 minutes for help depending on how many caregivers and servers were scheduled that day. A resident stated if you came early to meal service, then you would get better service but if you came in the middle to the end of service it takes longer . Continued 9099-C A resident stated the desserts were not coming out when the resident was done eating the meal, residents had to wait until all residents were served the meal then staff would serve the dessert at the end of the meal to all the residents at the same time, which took even longer if you came early to eat. Witnesses said the dining room is short staffed, and it takes longer to get meals ordered and delivered to the tables. Based on interviews this allegation is Substantiated at this time. This allegation was cited on Complaint # 29-AS-20250310142840 therefore it will not be duplicated on this complaint. On the allegations: Licensee did not ensure sufficient staff to provide activities to residents for several months. 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. Witness said the facility was having bingo at witness’s request, but the facility expected resident family members to call out the bingo numbers. Based on the evidence this allegation is Substantiated at this time. This allegation was cited on Complaint #29-AS-20250604132416 during the same period therefore it will not be duplicated on this complaint. On the allegation: The facility did not provide housekeeping services to common areas or residents rooms with clean linens 1 time per week for the past several months. A resident interviewed revealed not sure of the activity or housekeeping schedule any longer, not sure if the housekeeper was coming to clean or not, at times the caregivers were helping clean up the room and taking out the trash if they had the time. A witness said the dining room tables are left with food and sticky residue from prior meals. Witnesses interviewed noticed the common areas and apartments were not being cleaned like they normally were for a few weeks due to short staffing. LPA De Leon conducted a tour of resident 10’s (R10’s) room and once LPA entered the doorway the room had a strong urine odor. LPA took photos of R10’s bed and restroom which both needed cleaning and sanitizing. Staff interviews revealed 5 out of 7 staff stated R10’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. Continued 9099-C R10’s care plan revealed that R10 could not clean R10’s own room and restroom and this was to be completed by housekeeping staff. Staff stated that R10’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. R10 moved out of the facility, and according to interviews it took several cleanings to get the room back into rentable condition. Witness stated that resident rooms are supposed to be cleaned once per week, staff aren't cleaning the rooms, and resident 1’s (R1’s) room has gone weeks without being cleaned, if Witness calls facility to say the room hasn't been cleaned, staff will send someone to clean it, but it's supposed to be a weekly service, and it's not being done. Witness stated the bedding isn't being washed either. Based on evidence this allegation is Substantiated at this time. This allegation is the same deficiency as the one cited on Complaint #29-AS-20250604132416 during the same period therefore it will not be duplicated on this complaint. On the allegation: The Licensee/Administrator does not communicate with residents and responsible parties. Witness interview revealed Resident 1 (R1) was as breakfast and needed to use the bathroom. R1 pressed pendant R1 needed to go to the bathroom. Staff took R1 to R1’s room and just left R1 in the middle of the room and left without helping R1 to the bathroom. R1 was stuck in the wheelchair because the foot pedals were not in the right position and R1 could not reach R1’s walker. R1 called the front desk using R1’s cell phone and a staff member put the call through to another staff and R1 told staff what happened. Staff walked by and entered R1’s room and helped R1 to the bathroom. This is another situation where the agency staff were unable to communicate with a resident to meet an urgent need to use the bathroom. Witnesses said caregivers should be able to communicate with the residents to meet the care needs and staff not being able to communicate with the residents seems like it could be a very dangerous situation. Staff interviewed revealed the facility has had major turnover in several positions during 2024-2025 when Administrator vacated the position the communication lacked heavily, and several residents and responsible parties did not have questions answered or call back when they made inquiries regarding residents and the facility. Based on the lack of communication to responsible parties (RP) this allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.