complaint·March 11, 2026

(PAGE 2) Report continued from LIC 9099... On the allegations, Administrator is not at the facility for a sufficient amount of time and Administrator did not ensure the facility had a designated substitute in their absence it is the concern of the Reporting Party (RP) that the ED arrives between approximately 11:00 a.m.–12:00 p.m. and leaves between 3:00 p.m.–4:00 p.m. impacting timely decision-making regarding resident care while leaving no one in charge in their absence. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Staff interviews revealed that the ED is on site daily, Monday – Friday with the start time typically ranging from 8:00 a.m. to 9:00 a.m., and usually not past 9:00 a.m. due to a standing 9:30 a.m. daily Director’s meeting. The exact time may fluctuate depending on community needs, events, or coverage of NOC-shift schedules. Administrative staff, including the ED, make themselves available to residents and staff. If one director is not available, another director is present to address concerns. The ED is regularly on site and remains available after hours. During NOC shift hours, depending on the urgency of the issue, the Health Services Director (HSD) is contacted and “responds promptly”. The ED may also be contacted by staff or any of the other directors. It was noted that “There is always a director available either in person, by phone, or by text”. When the ED is not on site, a designee is always assigned. Typically, the Business Office Director serves as the designee; however, since the Business Office Director is currently new to the role, the HSD has been serving in that capacity. Residents are notified weekly via email and a hard-copy notice placed in their mailbox, which includes ED updates, community updates, and information on the designated manager on duty for specific days. Record review revealed that the ED is scheduled Monday through Friday from 8:00 a.m. to 6:00 p.m. During today’s visit, LPA obtained copies of the facility designee forms listing the Health Services Director, Maintenance Director, Memory Care Director, and Business Office Director. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur. Therefore, the allegations of Administrator is not at the facility for a sufficient amount of time and Administrator did not ensure the facility had a designated substitute in their absence are deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.