complaint·February 23, 2026

During the investigation, LPA interviewed the Cullinary Director, observed the kitchen/food, and reviewed the food menu for the month. According to the Cullinary Director and the food menu reviewed, there is a monthly food menus posted around the facility, along with the daily menu. Sandwiches get served everyday as an alternative option for residents who do not want to eat the main dish being cooked. Based on observation, LPA visited the facility on 12/26/25 and observed quiche with potatoes and steamed vegetables as the main dish on the menu for lunch. LPA observed the kitchen staff baking quiche, steaming vegetables and LPA observed ingredients for sandwiches. Regarding the allegation, facility staff do not respond to residents’ call button in a timely manner, according to the reporting party, staff do not respond to call bells in a timely manner, often taking 30 minutes or longer to assist residents. During the investigation, LPA interviewed staff, residents and reviewed call button response log. According to staff and residents interviewed, although response times vary due to overrall resident needs and the time of day, staff do respond to the call button requests. Based on call button response log reviewed, the average response time for staff to respond to a resident's call button is 5-10 minutes. Regarding allegation, facility staff are not distributing mail to residents, according to the reporting party, residents have not received any mail for the past two years. During the investigation, LPA interviewed staff, residents, and observed the mailing system. Based on observations, LPA observed a locked drawer next to the receptionist desk which maintains all residents' mail. According to the administrator, she denied this allegation and indicated that the front desk handles the mail when it comes in. The administrator and the receptionist indicated when mail gets delivered to the facility, the receptionists sorts it out and puts it in the accorded resident's slot in a locked drawer. According to staff and residents interviewed, residents receive their mail directly from the front desk and the residents who require assistance receiving their mail either has a family collect it for them or a team member will deliver it to the resident's room depending on what the resident requests. In addition, staff indicated, if residents don't retrieve their mail for a while, the front desk will call the resident or their responsible party to remind them that there is mail to be picked up. For memory care residents, the responsible party picks up the residents mail and for some of the independent residents, they will authorize someone else to pick up their mail if they are unable to. Staff will also deliver mail and packages if residents wish to have it delivered to their room. (Continue to 9099C) Regarding allegation, facility do not provide residents with transportation, according to the reporting party, there have been multiple occasions when R1 was not provided transportation to his/her medical appointments, despite the facility having a van designated for resident transport. During the investigation, LPA interviewed staff, reviewed the residency agreement, and reviewed the transportation log at the front desk. Based on residency agreement, the facility will make available to residents or otherwise assure the provision of scheduled transportation to health facilities, appointments, agencies, shopping, etc. According to staff interviewed, transportation is scheduled through a transportation log that is at the front from. All residents with or without their own personal cars can request transportation ahead of time and staff will try to accommodate the residents. If the facility drivers are unavailable that day/time because they are transporting other residents for their scheduled outing, the facility will accommodate the residents by paying for their taxi, uber, etc. Regarding the allegation, facility does not provide information about council meetings in a timely manner, according to the reporting party, announcements for resident and family council meetings are not posted in a timely manner. Notices are often posted only the day before the meetings, which results in low attendance among residents. During the investigation, LPA interviewed staff and observed the resident activity calendar for the month of December, along with previous months. Based on the activity calendar, LPA observed the resident council meeting on the activities calendar. LPA observed the date and time of the resident council meeting on the activities calendar. According to staff interviewed, resident council meetings are typically held on the third Tuesday or Wedneday of each month, however residents are aware of when the resident council meeting is because it is on the monthly activities calendar, in addition to daily activity calendar that is both projected on the facility television screens and hard copies are printed out and put in the front lobby. Therefore, based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with the Executive Director and a copy is provided.