complaint·August 1, 2025

The “Resident Incident Details Report” that was provided by facility, which shows 20 calls from R1’s room, dating from 04/13/2025 through 05/07/2025. 14 of 20 calls showed a response time ranging from approximately 11 minutes and 22 seconds (11:22) to 1 hour 49 minutes and 46 seconds (1:49:46) resulting in late responses average of approximately 41 minutes per late call, of the 14 late calls. And 1 minute and 35 seconds (1:35) average per the 6 acceptable call response times. At this time there is sufficient evidence to support the allegation of, “Facility did not answer residents call button in a timely manner.” and is substantiated at this time. Exit interview, report read, appeal rights and report provided. “Identified concerns and recommended actions take to resolve” entry to that form. LPA also noted that Outside Agency Service and Documentation form showed 52 prior visits without any additional concerns for R1 prior to the month of May 2025. Based on interviews, and documentation, there is not enough evidence to support the allegation of, “Facility did not ensure residents’ care needs were met.” and is unsubstantiated at this time. As to the allegation of, “Staff violated residents’ personal rights.” It was alleged that on 04/17/2025, R1 was not allowed to go to bedroom from the activity room. It was discovered through interviews and documentation that, on 06/26/2025, LPA Jeffries conducted an interview with S1, S2, and S3, all who stated that another Resident (R2) in Memory Care attempted to push R1 in their wheelchair into R1’s Room. All 3 staff stated that R1 and R2 were redirected back to the activity room for the safety of both residents. All 3 staff denied not allowing access to R1 to their room at any time other than R2 going into R1’s room for safety concerns. LPA Jeffries reviewed the staff schedule for 04/17/2025 and confirmed that S1, S2, and S3 were working in memory care on 04/17/2025. LPA Jeffries reviewed training for S1. S2, and S3 and all staff were current in the required staff training hours. R1 was no longer a resident at the facility and could not be interviewed. On 06/26/2025 LPA Jeffries attempted to interview R2, however R2 was not able to answer questions about 04/17/2025. At this time there is not enough evidence to support the allegation of, “Staff violated residents’ personal rights.” and is unsubstantiated at this time. As to the allegation of, “Facility was not maintained sanitary.” It was alleged that staff did not clean R1’s room or make R1’s bed, when wet with urine and floor had dried urine. It was discovered through interviews, documentation and observations that on 06/26/2025, LPA Jeffries conducted a physical inspection of the facility with focus on Memory Care Unit and room that R1 had resided over a month past. LPA noted that there were two housekeepers working in memory care unit and there were no overt smells and the facility and memory care appeared clean and in good repair. LPA noted that R1s former room was clean, floors were clean and discovered no issues in R1 former room. On 07/10/2025, 07/14/2025, and 07/22/2025, LPA conducted a physical walk through of the facility including memory care unit. LPA noted that the facility was clean and in good repair and noted at least two or more housekeeping staff working to clean rooms during these visits. LPA reviewed the facility schedule and noted that housekeepers were consistently scheduled during the months of April and May of 2025, additionally Care Staff was also consistently scheduled during April and May of 2025. Based on observations, and documentation there is not enough evidence to support the allegation of, “Facility was not maintained sanitary.” and is unsubstantiated at this time. Exit interview, report read, appeal rights and report provided.