Allegation: Staff do not ensure the facility is free of foul odors.

It was alleged that the facility hallway smells of urine and feces. To investigate the allegation, LPA toured the Assisted Living (AL) and Memory Care (MC) hallways, common areas, and residents’ rooms. During the tour LPA did not observe strong or persistent odors of urine/feces. Interviews were conducted with nine (9) residents residing in the MC and AL, the Executive Director, Memory Care Director, and six (6) Staff/Caregivers. The majority of residents described the facility as generally clean and odor free. Residents who were able to communicate stated that the housekeepers do daily light cleaning and weekly deep cleaning to their rooms. LPA checked random residents’ rooms and observed trash bins to be empty, and no soiled diapers were present inside residents’ rooms. Interviews with staff members stated that occasional short-lived odors may happen and described procedures for promptly cleaning incontinence related incidents happening in common areas and removing soiled linens and trash. All interviewees denied ongoing odor concerns and confirmed that hallways and common areas are cleaned and sprayed daily. Based on observations and interviews, the allegation that staff do not ensure the facility is free of foul odors is Unsubstantiated.

Allegation: Staff do not ensure the food being served is of good quality.

It was alleged that the Staff do not ensure the food being served is of good quality. To investigate the allegation, LPA interviewed nine (9) residents residing in the MC and AL, the Executive Director, Memory Care Director, the Chef and six (6) Staff/Caregivers. LPA observed the meal service and reviewed the facility’s description of menu planning and substitutions. Residents interviewed regarding meal quality, variety, and whether they were regularly served poor quality food. Residents confirmed that meals are acceptable and varied. Residents also stated that there is always alternative food for each mealtime and added that variety of sandwiches are always available as a substitute for the main meal. Interviews with staff members stated sandwiches are served at times as part of meal options when residents refuse the main meal.

Continue on LIC9099-C

Allegation: Staff do not ensure resident's personal belongings are safeguarded.

It was alleged that staff do not ensure residents’ personal belongings are properly safeguarded. To investigate this concern, the LPA interviewed nine residents from the Memory Care (MC) and Assisted Living (AL) units, as well as the Executive Director, Memory Care Director, and six staff members, including laundry staff. Laundry staff explained their process for collecting, sorting, washing, drying, and returning clothing, noting that each resident follows an individual laundry schedule and that all loads are washed separately. They also stated that residents’ clothing is labeled with their names to prevent items from being misplaced. Residents interviewed reported that they have not experienced missing clothing after laundry service. Some residents mentioned that clean clothes are occasionally returned in bags, but staff later organize them in the closets. During room checks, the LPA observed only unwashed clothing in laundry baskets and did not find clean clothing stored in bags. Staff further explained that some Memory Care residents place their own clothes into bags because they believe they are preparing to leave the facility. All staff denied leaving clean clothing in bags for a long period of time after washing and stated that residents sometimes misplace their own items in different drawers or forget where they placed them. Staff also noted that residents, mainly residing in Assisted Living, occasionally give clothing to one another and later report the items missing. Interview with the Executive Director revealed that the facility conducted an internal investigation regarding a missing ring. Staff were interviewed and relevant areas were checked; however, no witness reported seeing or hearing anyone take the ring. The investigation did not reveal any suspicious behavior or evidence indicating how or when the ring went missing. Based on the observation and information gathered, the LPA did not obtain evidence that staff failed to safeguard residents’ belongings or that facility practices resulted in lost personal property. Therefore, the allegation is Unsubstantiated.

Continue on LIC9099-C

It was alleged that staff restricted a resident’s access to personal grooming items without authorization. To investigate this concern, the LPA interviewed nine residents from the Memory Care (MC) and Assisted Living (AL) units, as well as the Executive Director, Memory Care Director, and six staff members. Staff explained that certain toiletry items may be secured based on individual resident needs—such as cognitive impairment or required supervision—and that items are provided during ADL care to ensure residents receive appropriate oral hygiene and grooming support. Staff also noted that all bathroom cabinets in the MC unit are kept locked to protect residents’ health and safety, as some residents may wander into others’ rooms. Residents interviewed reported that staff assist them with hygiene and always provide necessary items. During room checks in the MC unit, the LPA observed that bathroom cabinets were locked, and no hygiene or potentially unsafe items were accessible without supervision. Based on these observations and interviews, the LPA determined that the facility safeguards residents’ health and safety by securing bathroom cabinets in the Memory Care unit; therefore, the allegation is Unsubstantiated.

No Deficiency cited during today's visit.

Exit interview conducted and a copy of this report signed and delivered.