Complaint Investigation Report

LPA review of the facility call system records for resident calls from 4/1/2025 to 5/1/2025 revealed 130 pendant calls and 10 resident bathroom pull cord alerts with response times over 10 minutes; of which 16 were over 20 minutes, 12 were over 30 minutes, and 6 were over 60 minutes. LPA staff interviews revealed there are times that residents have to wait for extended periods of time to receive assistance since staff are helping other residents. Staff also stated in interviews that the call system does not always function properly, sometimes losing Wi-Fi signal and other times they forget to follow through timely completing all the steps of restoring resident pendant and bathroom devices. LPA resident interviews revealed 6 of 7 interviewed residents state they do sometimes wait for extended periods of time for staff to respond. Based on all interviews conducted and record review, at this time the above allegation was found to be substantiated , there is a preponderance of the evidence to prove that the alleged violation occurred.

On allegation: Residents are not being provided clean linens. It was alleged that staff are covering the dirty areas of the linens and not providing residents with clean linens. LPA interviews with staff revealed that care staff in the memory care unit are responsible for changing linens 2-3 days each week and more often when soiled. Staff interviews in the assisted living unit revealed housekeepers are responsible for changing sheets once per week and care staff are responsible for changing the linens when soiled. During multiple visits to the facility from 3/17/2025 and 7/8/2025 LPA observed and photographed 7 resident rooms with soiled and stained linens. Additionally LPA noted 6 rooms with stained and soiled mattresses and/or mattress covers. Based on LPA observation, at this time the above allegation was found to be substantiated , there is a preponderance of the evidence to prove that the alleged violation occurred.

On allegation: Staff does not keep facility free from odor. It was alleged a resident in memory care, Resident #3 (R3), urinates on the floor of their room, the room smells of urine and staff do not always clean it up. On 5/7/2025 LPA and Administrator toured the facility including R3’s room. LPA noted a very strong smell of urine. Upon inspection of the room at 11:54am LPA and Administrator noted in the south/east corner of the room the laminate floor boards, baseboard, and paint on the walls peeling away from the floor and walls. Administrator stated this is due to the resident urinating in various areas of their room including that corner and there was a plan to repair the flooring, baseboard, and paint.