Complaint Investigation Report

On 01/14/26, LPA interviewed staff S1, S3, S4 who stated that the typically response times of are approximately 15 to 20 minutes but stated delays may occur when staff are assisting other residents or during periods of high workload.

Based on record review of pendant call logs for R1 from 08/01/25 through 12/31/25 there were 316 documented activations. Of those, 61 calls had response times ranging from 21.2 minutes to 67.8 minutes, with the longest recorded response time of 67.8 minutes on 08/07/25. Although delayed responses were not directly observed during the investigation, the facility’s records document multiple instances of extended response times.

Allegation 4: Facility staff did not ensure the kitchen is kept sanitary - ***AMENDED - DUE TO ADDITIONAL INFORMATION received see LIC 9099A.***

Based on observations and interviews, during the initial inspection conducted on 09/12/25, LPA observed conditions in the kitchen that were not maintained in a clean and safe manner. LPA observed ice accumulation on the freezer floor creating a slippery surface, indications that maintenance of the freezer unit was needed. Photographs were taken at the time of observation. LPA observed used rags on the food preparation area and an open trash bin. LPA checked and observed that the refrigerator temperature was at 50 degrees Fahrenheit, which exceeds the required range for safe food storage. The freezer temperature was measured at 0 degrees Fahrenheit, which is within regulatory range. LPA interviewed 2 kitchen staff (KS), 1 out of 2 staff stated that there was a call out and had to pull a double shift. 1 out of 2 staff stated, 2 people work in the kitchen. **2 kitchen staff (KS1 and KS2)**

On 01/14/26, LPA interviewed staff S1, S2, S3, S4 stated that caregivers are not permitted in the kitchen and did not report direct observations regarding kitchen sanitation conditions.