Complaint Investigation Report

Facility did not provide assistance with dressing in a timely manner:

The allegations are that the facility did not provide assistance with addressing in a timely manner and facility did not provide food service.

On 10/19/2025, RP alleged that food service of Memory Care Unit residents were not provided assists with dressing in a timely manner and their breakfast service were delayed.

On 10/30/2025, LPA interviewed Executive Director (ED) Karen Nickolai. ED stated that on 10/19/2025, 3 caregivers and 1 medication technician in AM shift called out for work. There was only 1 caregiver who reported to work. There were 32 residents in care. ED stated he/she pulled 5 staff from food service and housekeeping service departments to assist residents with wake up dressing service and breakfast service.

ED stated there were family members from 3 residents visited the facility on 10/19/2025 morning, they also assisted the residents with dressing service and breakfast service at that time period.

ED stated residents were dressed up in the morning on 10/19/2025 and breakfast were served to residents, even though some delay for breakfast.

On 10/30/2025, LPA interviewed Executive Cook (S1). S1 confirmed he/she and Maintenance Director (MD), 2 housekeepers, and a dishwasher were pulled to assist residents for wake up dressing service and breakfast service on 10/19/2025 morning.

LPA interviewed 6 staff. 6 Out of 6 staff stated morning shift staff assist residents with their morning routine including dressing and breakfast services. 6 Out of 6 staff stated they did not hear any resident was left in the room without breakfast due to neglect.

LPA interviewed 7 residents. 3 Out 7 residents stated they walk to dining room for meals and they do not have any complaints against the facility. 4 Out of 7 residents were unable to answer questions due to cognitive disorder.