The complaint alleged that resident R1 had experienced multiple un-witnessed falls and that facility staff was delayed in responding to R1's needs. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegations. A1 stated that when staff found R1 on the floor of R1's room, they called the Med Tech or Nurse to evaluate R1. However, R1 consistently refused assistance, insisting that they were fine and had no pain. A1 also explained that for any resident who experienced an un-witnessed fall, staff would always call the Med Tech or Nurse to assess if the resident was in pain; if there were any injuries, they would immediately call Medical Emergency Services (MES).

The department also interviewed the Licensed Vocational Nurse (LVN), who denied the allegations, stating that when staff discovered an un-witnessed fall, they would call the Med Tech and Nurses to conduct evaluations. If any injuries were found, they would contact MES right away.

On the same date, the department interviewed the Medical Technician (MT1), who also denied the allegations and confirmed that they follow procedures regarding un-witnessed falls by contacting the LVN for resident assessment.

Additionally, the department spoke with two staff members (S1 and S2), who similarly denied the allegations and stated that for un-witnessed falls, they would call both the MT1 and LVN to assess the residents, regardless of whether the residents reported pain or injuries.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated.

Allegation #2: Staff do not respond timely when resident falls.

The complaint alleged that the facility staff delayed their response to Resident 1's (R1) care. On August 19, 2026, the department interviewed the Administrator (A1), who denied this allegation. A1 stated that each resident has a call button around their neck or in their pocket that, when pressed, prompts a staff member to respond. The Administrator also mentioned that R1 knows how to ask for help and communicates very effectively. A1 also stated R1 had multiple un-witnessed falls without any injuries; R1 always refuses Medical Emergency Services (MES) and stated there was no pain and that they were feeling fine.

On the same day, the department interviewed the Licensed Nursing Volunteer (LNV), who also denied that staff delayed their response to residents. According to LNV, residents pressed the call button for assistance, and a staff member responded within minutes.

The department interviewed ten additional residents (R2-R11), all of whom reported no neglect while seeking help. On August 19, 2026, the department observed two residents pressing their call buttons, and staff arrived eight minutes later. The department also reviewed the hospital discharge papers for R1, dated from February 3, 2026, to March 4, 2026, which indicated that R1 had been hospitalized several times for various symptoms. Additionally, the department examined the physician's report for R1, which confirmed that R1 was capable of performing activities of daily living independently and managing self-medication.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated.

The complaint alleged that a family member is concerned about wounds on the resident's left heel that allegedly have not healed properly. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that the facility nurse had observed a wound on the resident R1's left heel. After the wound evaluation and treatment, the facility contacted Bayview Hospice, and R1 agreed. On April 04, 2026, R1 started Hospice care treatment with Bayview Hospice. A1 stated after enrolling in Bayview Hospice, R1 decided to discontinue hospice care services. On April 23, 2026, the facility, staff members, a representative from Bayview Hospice, and R1's family were present when R1 decided to discontinue hospice care. Staff explained to R1 the benefits of receiving hospice assistance for wound care. Because the facility is not a medical center, staff took the time to explain R1's wound situation to the resident, who is independent and does not have a Power of Attorney (POA).

On August 19, 2026, the department interviewed the Licensed Vocational Nurse (LVN), who denied the allegations and stated that the facility could not provide wound care to residents. Instead, the facility would contact Hospice Care and home health services to assist residents with wounds. The LVN emphasized that R1 needed support from one of these services, as the facility is not a medical facility. The department also reviewed the Bayview Hospice notes from the same date, which indicate that services were started and then discontinued for resident R1. The department also viewed a picture of R1's left foot tapes, which shows that R1 had a wound on the left foot.

The complaint alleged that a family member had several concerns about safety, hygiene, and the care provided in the resident's assisted living. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that Resident 1 (R1) can perform activities of daily living (ADLs) independently. R1 has a scheduled shower three times a week. A1 also stated that all staff members must follow the resident's physician reports and the service plan to assist residents with their hygiene needs. If a resident can’t, the staff would assist with the (ADLs) activities.

On August 19, 2026, the department interviewed the Licensed Vocational Nurse (LVN), who also denied the allegation and confirmed that the staff adheres to the resident's physician report, doctor’s orders, and service plan to meet the resident’s hygiene needs accurately.

The department also interviewed the Medication Technician (MT1), who denied the allegation and stated that they follow the resident's service plan to meet hygiene needs.

The department interviewed two staff members, referred to as S1 and S2, both of whom denied the allegations. They confirmed that they have access to residents' face sheets, service plans, and shower schedules for each resident. They clarified that residents in a specific program are entitled to three showers per week. For private-pay residents, the number of showers is determined by how many the residents choose to purchase.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated.

Allegation #5: Staff did not ensure the facility is kept sanitary and free from pests.

The complaint alleged that the complainant saw rodents and cockroaches in resident R1's bedroom. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that Dewey Pest Control visits the facility weekly. A1 also stated that the facility rotates residents' rooms weekly. If a resident complained that a room had pets, the company would service the rooms and follow up the following week.

On August 19, 2026, the department interviewed two staff members (S1-S2), both of whom denied the allegation and stated that pest control visits the facility weekly; if there is a problem with a resident's room, they let them know. Additionally, the department interviewed ten residents (R2-R11); 9 of 10 residents denied seeing any pets in their rooms and stated that pest control visits the rooms sometimes. On August 19, 2026, the department visited eight rooms: 315, 316, 317, 318, 272, 219, 217, and 114.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated.

Allegation #5: Staff did not ensure the facility is kept sanitary and free from pests.

The complaint alleged that the complainant saw rodents and cockroaches in resident R1's bedroom. On August 19, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that Dewey Pest Control visits the facility weekly. A1 also stated that the facility rotates residents' rooms weekly. If a resident complained that a room had pets, the company would service the rooms and follow up the following week.

On August 19, 2026, the department interviewed two staff members (S1-S2), both of whom denied the allegation and stated that pest control visits the facility weekly; if there is a problem with a resident's room, they let them know. Additionally, the department interviewed ten residents (R2-R11); 9 of 10 residents denied seeing any pets in their rooms and stated that pest control visits the rooms sometimes. On August 19, 2026, the department visited eight rooms: 315, 316, 317, 318, 272, 219, 217, and 114. The department observed no pets or cockroaches during the room inspection.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unsubstantiated.

No deficiencies were cited.

An exit interview was conducted. A copy of this report was provided to Administrator Suzette Johnson.