Allegation: "Staff are not following residents dietary plan." It is alleged that staff are unaware of residents' dietary plans and restrictions, leading to cross-contamination of food allergens. It is also alleged that a resident was served cross contaminated food, and there was a choking incident two to three months ago due to staff not chopping food. (6) of (6) staff interviewed denied the allegation, stating that a process is in place anytime a resident's diet is changed. S1 stated that a dietitian is involved in meal planning to meet the residents' dietary needs. Some staff explained that whenever there is a new resident with a special diet or dietary changes, a diet order is generated and sent to the food services director, who then notifies the kitchen staff. S5 stated that the kitchen has a dietary board list of allergies and restricted diets along with pictures of the residents. Residents interviewed denied the allegation, stating that staff are aware of their dietary plans and restrictions. Some residents indicated that they have seen a resident coughing while eating but not choking. LPA reviewed incident reports (January-June 2026) submitted to CCLD and found no incidents of food allergen cross-contamination or choking. Records reviewed indicated that the kitchen staff have the proper food handling and safety training. During the visits on 06/30/2026 and 07/24/2026, LPA observed the board in the kitchen that staff could see and there was no inappropriate food served during lunch. Therefore, there was insufficient evidence to corroborate with this allegation.

Allegation: "Staff do not respond to residents call for assistance in a timely manner." It is alleged that residents are left waiting for 30-40 minutes when they are using their pagers. All (6) staff interviewed denied the allegation of slow response times, stating that caregivers attend to residents' calls as quickly as possible and have received training. Staff confirmed that they have adequate staffing who provide care and supervision, including night and on-call staff, and they also follow residents’ care plans. Staff explained that calls are prioritized based on urgency, such as life-safety emergencies or falls, and caregivers use walkie talkies to communicate about calls for assistance. S2 stated that they monitor response times to ensure calls are attended promptly, otherwise, the call will repeat itself, until the resident has been assisted. Other staff interviewed stated that residents do not use pagers, but they have call lights in their rooms (by the bed and bathroom) or wear pendants (optional with fee). All (12) residents interviewed denied the allegation and (5) of (12) residents who have pendants stated that staff respond to their calls immediately. Some residents stated they can manage their daily chores with minimal assistance. In order to measure call response times, at 11:05 am, LPA pushed the call light in Room #254 during the visit on 07/24/2026, and it took staff 02:55 minutes to respond. During both visits, LPA observed the residents to be clean and interact well with staff and other residents. Therefore, there is insufficient evidence to corroborate the allegation.

Based on statements and interviews conducted with staff, residents, review of resident/staff files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was provided to the Executive Director, Mary Mims-Burris.

Allegation: "Staff are neglecting residents in care." It is alleged residents were abandoned in the dining room and residents with dementia are left outside for four hours causing the residents to get sunburned without staff checks. All (6) staff interviewed denied the allegation, stating that they completed training on neglect/abuse and would never leave residents outside for so long. Staff stated that although they have meal schedules, residents may stay in the dining room after mealtimes. Staff also stated they are always on the move, and they would have seen if resident(s) remained there for a long time, and if so, they would have paid attention to them. If the residents want, staff in memory care unit can take them to the courtyard next to the dining room, where staff are around to watch out for them. All (12) residents interviewed denied the allegation, stating that they were welcome to spend time in the dining room or anywhere in the common areas and were never left alone. Some residents stated they enjoyed sitting outside but did not get sunburn because they stayed in the shade and staff regularly checked on them. During the visits on 06/30/2026 and 07/24/2026, LPA observed positive interactions between staff-residents. Therefore, there was insufficient evidence to corroborate with this allegation.