Complaint Investigation Report

The allegation of “Staff don't respond to resident in a timely manner.” Alleges that facility staff did not clean R1’s room, do R1’s laundry, or take R1’s food orders in a timely manner. LPA interviewed R1 who stated that due to their health conditions they required food to be delivered at specific times during the day. R1 stated that when they originally began tray service they would place their food orders for the kitchen by writing down their requests on the daily menu which a caregiver would deliver to the kitchen to prepare. R1 stated that this led to delays in receiving their food in a timely manner so they were instructed to call in their order to the front desk. R1 stated that on multiple occasions food was not delivered or was left outside of their door without any notification that the food had arrived. LPA interviewed the Director of Dining (DD) who confirmed that the facility had requested R1 to call the front desk to place orders for delivery. DD stated that they expect R1’s call at certain times during the day and if they did not hear from R1 they would personally call to take R1’s order. Regarding the laundry service at the facility LPA interviewed R1 who stated that they were supposed to receive laundry assistance once per week but laundry was often completed late or missed by staff. LPA requested monthly task logs for laundry assistance provided to R1 between January - March of 2025. LPA reviewed the logs that the facility had submitted and observed that between 01/15/2025 and 03/14/2025 all Fridays showed laundry assistance as “Task Not Completed” (TNC). LPA interviewed ED-I who informed LPA that the facility had swapped to a different record keeping system around that time and any logs prior to the implementation of that system would show as “TNC”. The ED-I informed LPA that they were unable to pull any previous records for laundry assistance as those records are only retained for one (1) year. Regarding R1’s room not being cleaned in a timely manner, LPA interviewed R1 who stated that facility staff often did not make their bed or take out the trash from their room in a timely manner. LPA observed R1’s room on 02/09/2026 and observed two (2) trash cans which were full, multiple used towels on the floor of the bathroom, and trash on the sink counter. LPA reviewed evidence submitted and observed notes which indicated that R1 did not receive assistance with taking out the trash or making the bed on 02/08/2026, 02/02/2026, 01/29/2026, 01/22/2026, 01/17/2026, and 01/15/2026. Ten (10) additional dates were observed between 12/16/2026 - 02/08/2026 where assistance with either taking out the trash or making the bed was not provided. Based on the information obtained during observation, record review, and interviews there is sufficient evidence to support the allegation of “Staff don't respond to resident in a timely manner.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiencies were cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.