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32 | Staff responded promptly, knocked several times, and eventually spoke with R1, who insisted they did not press the pendant. Other residents and staff reported that checks are done approximately every two hours for all residents. R1’s care plan dated September 16, 2025, indicated that R1 is independent in bathing, grooming, dressing, meals, toileting, and ambulation. Based on interviews and documentation, there was no evidence that supervision requirements were violated.
It was reported that R1 did not eat red meat and sometimes the only alternative is chicken tenders, which was described as overcooked and hard to chew. They also mentioned salads sometimes come without dressing and that food quality varies depending on which chef is working. R1 stated the food is often bland and lacks seasoning, but when the “right chef” is working, meals taste much better. During the visit, R1 called the front desk to order food and was offered herb-grilled fish, garden rice, and vegetables, which they accepted. Staff confirmed R1 is vegetarian and that they communicate this to the kitchen. Staff stated that R1 often requests specific items and is vocal about their preferences. Other residents stated that while food tastes like “cafeteria food,” alternatives are offered if requested. Kitchen staff reported that they can prepare various options for residents, but requests need to be made in advance. Records and interviews show the facility provides options and accommodates special diets. No evidence was found that food service requirements were not met.
It was reported that the facility had a power outage from 7:00 PM to 10:00 PM and no emergency lights or flashlights were available. Staff and maintenance interviews confirmed a power outage occurred approximately two weeks ago, lasting between 30 and 60 minutes. The maintenance director stated the outage began around 6:00 PM and the facility does not have a backup generator but does have emergency lighting and illuminated exit signs that activate immediately during a power outage. Staff stated they did their best to assist residents during the outage and that emergency lights were functioning. Based on interviews and observations, there was no evidence to support that emergency lighting was not maintained.
R1 stated they were not given a reason for the rent increase. Records show that on September 22, 2022, R1’s representative signed an addendum explaining average monthly fee and level of care increases. On October 20, 2025, the facility issued a written notice explaining that costs had increased due to market conditions, operations, and overall expenses, and therefore rates were adjusted effective February 1, 2026. The notice stated that the facility continually analyzes the market, their operations, and financial strength, and that increases in costs associated with operating the facility and providing quality services led to the adjustment.
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