Staff members interviewed were not aware of an issue regarding residents' receiving tray service when needed and management stated they had not received any complaints from residents or family members regarding food service. Staff informed that most residents eat meals in the dining room during meal times. The facility offers three (3) meal services, all of which have two serving times: 7:30am/8:30am, 11:30am/12:30pm, 4:30pm/5:30pm. Tray service is an additional charge that can be requested from residents or included in their service plan upon admission. If a resident is unable to attend dining room service due to being sick, the facility will provide for (4) complimentary tray services per month. Tray service is an agreement signed by the resident, and information about the service is provided in the Residency Agreement. At the time of interview, less than five (5) residents were on the list for tray service.

Review of the facility's Residency Agreement showed that the facility provided three (3) meals plus snacks as a basic service. The document stated that residents could pay an additional $10 for each tray service, and corroborated staff interviews that residents could receive four complimentary (4) sick trays. The facility's food menus showed an extensive variety of food options, with meals including protein, vegetables, and a dessert for lunch and dinner.

LPA directly observed the facility's food service during an announced facility visit. The food was observed to be of good quality and variety, absent of indications that it was not fresh or improperly cooked. LPA additionally observed three (3) separate staff delivering food trays to respective resident rooms while the other residents were eating in the dining room.

Resident interviews revealed no concerns regarding tray service or food service at the facility.

Outside sources interviewed did not express concern about food service at the facility.

Regarding the allegation, "Staff did not respond to residents' call button" and "Licensee did not provide supervision residents", it was alleged that staff did not respond to a resident's call for an extended period of time and that staff did not meet resident care needs due to inadequate supervision.

Staff members interviewed had not observed long wait times. Staff noted that, at times, residents have misperceptions of how long they have waited. A staff member offered an example of a resident who claimed they had waited twenty (20) minutes for help, however the computer system showed that the wait time was approximately five (5) minutes. Staff additionally informed that there were times when a resident was tended to timely but the staff member forgot to clear the call. (Continued on LIC9099 p.3)

Staff informed that resident pendant calls specifically alerted the staff working on the respective floor during each shift, and that the concierge was also utilized to let staff know when a pendant call remained on the screen after fifteen (15) minutes.

Records review revealed that the average staff response time during a sample period was 11 minutes, 6 seconds. Review of Resident Council Meeting notes prior to the complaint showed that four (4) new staff members had been hired. The notes were absent of resident complaints regarding pendant response times. Review of staff assignments and schedules showed that 3-4 staff were assigned to each floor, depending on shift, with two (2) Med Techs on the AM and PM shift. The schedule additionally showed that a Licensed Vocational Nurse (LVN) was present during AM shifts, as well as the Wellness Director who is a licensed medical professional. The facility's Residency Agreement revealed that activities of daily living (ADL) assistance was provided to residents per their level of care.

Residents interviewed did not express concern regarding pendant response times or staff supervision.

Outside sources interviewed did not express concerns about pendant response times.

During and unannounced facility visit LPA directly observed staff assisting residents and responding to resident pendant calls. LPA observed the call log screen twice during the visit, observing no outstanding pendant calls. LPA observed specific staff pagers during interview, with none showing pendant alerts with egregious wait times. LPA additionally observed staff approach residents without being paged in common hallways and in the dining room. LPA overheard the concierge inquire about an outstanding pendant call, and the staff responsible for the section informed that they were assisting another resident but would be there shortly.

Regarding the allegation, "Licensee did not provide opportunities for socialization", it was alleged that residents were left without social interaction.

Staff interview revealed that two volunteers visit the facility 1-2 times per week and offer activities such as arts and crafts, horse race derby games with prizes, bingo, or walk around and engage with residents. Staff informed that caregivers intentionally invite residents to the scheduled monthly and daily activities.

(Continued on LIC9099 p.4)

The facility also produced a community newsletter for residents, and all monthly and daily activities were posted around the facility. Staff stated that residents will also sit and chat with each other in common areas around the facility.

Residents interviewed did not express concern regarding activities and socialization opportunities at the facility.

Outside sources interviewed did not express concerns regarding the socialization opportunities for residents.

The facility's Residency Agreement shows that socialization activities are a basic service that the facility provides. The facility's monthly Activity Schedule showed an extensive variety of activities for residents to gather and socialize, with 6-11 activities being offered each day in the month of August 2025. One exception was on 08/30/25, which offered 3 activities plus a facility-wide Luau Party event.

During unannounced facility visits LPA directly observed residents gathering in various parts of the facility and engaging with each other. LPA observed residents sitting in groups chatting, eating meals together, playing games, and being entertained by live performers. Additionally LPA has observed staff members approach residents sitting in common areas to ask how they were doing, as well as stopping to speak with residents in passing in hallways.

Regarding the allegation, "Licensee did not ensure facility was sanitary", it was alleged that resident rooms and common areas were inadequately cleaned, malodorous, and contained trash.

Staff members interviewed informed that the housekeepers pick up trash daily inside and outside of the facility, vacuum multiple times per week, wipe down surfaces in common areas. Staff informed that each resident room is cleaned once per week, and caregivers help to maintain this. Caregivers clean up spills when they occur and housekeeping is called to clean and sanitize accidents that occur in the common bathrooms.

Residents interviewed did not express concern regarding the cleanliness of the facility or their rooms.

Outside source did not express concern regarding the facility's cleanliness.

(Continued on LIC9099 p.5)

Records review revealed a weekly cleaning schedule where 6-9 resident rooms were cleaned each day of the week. This schedule accounted for all occupied resident rooms plus common areas. Cleaning checklists show detailed steps for resident rooms and common areas to be cleaned; this form included check boxes for staff to mark when each task was complete. The facility's Residency Agreement showed that housekeeping was a basic service that the facility provides to residents.

During multiple unannounced facility visits LPA observed common areas and resident rooms. No clutter, debris, or malodor was observed. An extensive observation of facility cleanliness was conducted during the unannounced visit on 08/18/2025. No odors, clutter, or debris was found. A sample of random resident rooms were found to be clean, organized, and sanitary. Housekeeping was observed going in and out of resident rooms per the weekly cleaning schedule.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Director of Health and Wellness Raquel Mathews to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.