Through observations and interviews the facility is not providing an unknown substance to residents in care. R1 stated they feel tired after they eat. S1 stated that R1 likes to prepare their own meals, but will continue to monitor R1 as they have type 2 diabetes and food can affect his tiredness. S1 provided LPA with a copy of the menu along with R1’s medical assessment which stated that R1’s blood sugar needs to be monitored. R2 stated they do not believe anything is being added to the food.

Staff does not ensure facility is free of mold.

During a tour of the facility, no mold was observed on the premises. R1 explained their concern stemmed from the runoff valve from the AC unit. LPA inspected runoff and observed water on the side of the facility near a drain. AC unit has not been relocated and is original to the facility. LPA observed no concerns with mold at this facility.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator.

R1 moved into the facility on 07/09/25 and was not seen by home health until 08/07/25. R1 was placed in the facility through an agency that set up home health care. S1 stated they helped facilitate care for R1 through home health. S1 also stated that have been trained by home health in changing out bandages for wound care.

Staff does not accord resident privacy.

LPA observed R1 resides in a single room with no roommates. R1 states staff are entering their room without permission, but staff have stated they do not enter a room without knocking. Interviews with other residents have confirmed staff announced themselves before entering a bedroom.

Staff does not ensure resident's call button is in good repair.

LPA observed call buttons in the bedrooms of the residents. LPA was informed from S1 that the call buttons are not operable and have not been operable for several years. S1 explained they do not pay for the service anymore and informed R1 before moving in. R1 told LPA they were upset that the call buttons are in the room, but can’t be used. LPA reviewed admission agreement and it does not included information regarding the call button.

Staff does not ensure facility has adequate laundry detergent supply.

LPA observed 15 bottles of detergent in the garage of the facility. S1 stated that residents can do as much laundry as needed, but must be courteous to other residents that may need to use the washer and dryer. After reviewing the admission agreement, there are no rules that limit how many loads of laundry can be completed at the facility and they must provide detergent for residents to wash their clothes.

Staff does not ensure facility plumbing is in good repair.

In July of 2025 the facility experienced a clogged kitchen sink drain. The facility provided a copy of the plumbing bill to fix the clogged drain. S1 stated that as soon as they knew it was clogged, a plumber was called. Upon visit on 07/28/2025 LPA did not observe any clogged or backed up sink in the facility.

R1 said it was too cold in the facility. The facility closed the vent in their room to help accommodate R1. Staff did not adjust the temperature since the 4 other residents felt comfortable. R2 stated that the temperature was comfortable and R1 was the only one complaining. LPA observed temperature at 73 degrees Fahrenheit on 08/07/2025. Through interviews with other residents and staff, this was a comfortable temperature for everyone.

Staff does not safeguard resident's personal items.

Through interviews it was determined that R1 did not have any personal items stolen and was upset there was no lock on the door. R1 wanted to add a lock, but S1 stated they could not due to safety concerns. R1 was wheelchair bound and incase of emergency, might not be able to unlock the door for entry.

Staff does not ensure smoke detectors are in good repair.

Through the initial tour on 07/31/2025 LPA observed smoke detectors located throughout the facility. S1 stated that they are being replaced with new batteries and will be reinstalled. LPA observed smoke detectors in all areas of the facility. LPA activated the alarm to ensure they are operational. LPA has no concerns with smoke detectors within the facility.

Staff does not follow resident's admissions agreement.

LPA reviewed R1’s admission agreement which listed the correct room. R1 originally was going to move into a smaller room, but decided not to because the room they are currently in has a personal bathroom. Administrator updated admission agreement to reflect this change and provided a copy for R1.

Staff did not provide a copy of the admissions agreement to resident.

Through interviews, R1 provided a copy of the admission agreement given to them from the Administrator. This allegation is unfounded as R1 did receive a copy of the admission agreement.

A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility.