It is alleged that the dining room chairs, tables, floors and walls are dirty and have been for weeks. It is also alleged that staff are supposed to mop and have the tables and floors clean and ready for the next mealtime but are not doing so and that dirty dishes are mixed with clean dishes.

Staff deny the allegation. Five (5) staff who oversee and work directly in the kitchen’s operations indicated that chairs, tables, floors and walls in the dining room are cleaned daily and have not remained dirty for weeks. Chairs, tables, floors and walls are cleaned after each meal service and as needed.

Clean and dirty dishes are not mixed. Procedures are in place to properly store clean and dirty dishes. Staff further indicated that the floors are mopped after lunch and dinner meal services or as needed.

Eleven (11) out of (12) residents indicated that they are not concerned about the facility’s cleanliness because they consider the facility to be clean and sanitary, including the dining room.

During inspection of the dining rooms, LPA observed. chairs, tables, floors and walls to be clean and sanitary. LPA also monitored the breakfast and lunch meal services and observed that staff cleaning and sanitizing high traffic areas.

Furthermore, a review of the facility’s Server Duties Logs for May – June 2026, was conducted. It was observed that chairs, tables, floors and walls are part of the routine cleaning tasks executed throughout the day. An audit of the facility’s cleaning supplies was also conducted during the visit. LPA observed that the facility has sufficient cleaning supplies readily available for use. Interviews, observations and record review do not corroborate the allegation that staff do not ensure the dining room is clean.

Regarding: Staff do not clean feces, blood, or urine off of common area surfaces.

It is alleged that fecal matter has been on the walls in and outside of the dining rooms for weeks. It is also alleged that there is a presence of urine, blood and feces in the common areas which are not cleaned by staff.

Staff deny the allegation. Interviews with (11) out of (11) staff indicated that the walls in and outside of the dining rooms do not have fecal matter, urine or blood. Staff stated that there is no presence of urine, blood or feces in the facility’s common areas. Staff also indicated that the walls around the facility are not left without being cleaned for weeks. Interviews with (6) staff who oversee and work within the facility’s food service department indicated that the dining rooms are cleaned after every meal service, which includes wiping down the walls. ***Continues on LIC 9099-C page 2***

Interviews with (8) out (12) residents indicated that they have not observed fecal matter or blood on the walls of the facility. Three (3) residents indicated that they do not eat in the dining areas but have not observed feces or blood on the walls of the facility. Eleven (11) out of (12) residents indicated that they are not concerned about the facility’s cleanliness because they consider the facility to be clean and sanitary. During inspection of common areas and dining rooms, LPA found all wall surfaces clean and free of dust, dirt, or biohazards. LPA also monitored the breakfast and lunch operations, observing that staff maintained proper cleaning protocols between services and routinely sanitized high-traffic areas. LPA also observed that staff are on hand to assist residents with their incontinent care needs during meal services if needed. Furthermore, a review of the facility’s Server Duties Logs for May – June 2026, was conducted. It was observed that the cleaning of walls is included as part of the routine cleaning tasks executed throughout the day. An audit of the facility’s cleaning supplies was also conducted during the visit. LPA observed that the facility utilizes commercial-grade cleaning products formulated to mitigate infection, eliminate pathogens, and prevent cross-contamination in food service and resident care areas.

Interviews, observations and record reviews do not corroborate the allegation that staff do not clean feces, blood, or urine on common area surfaces.

Regarding: Staff retains residents whose presence poses a health and safety risk to other residents.

It is alleged that a resident has been physically abusive toward another resident and staff are not doing anything about it.

Interviews with (6) staff revealed that staff provide care and supervision to residents who live in the facility, including behavioral intervention when necessary. Staff indicated that they are trained to respond to aggression between residents by re-directing and de-escalating.

***Continues on LIC 9099-C page 3***

Interview with HN revealed that R1 experienced health changes which altered their behavior. RN stated that RN discussed a protocol with facility staff to monitor R1 for UTI and to continue to encourage R1 to take their medication to help prevent agitation. RN stated that they do not feel that R1 is a danger to other residents; however, RN has had 1:1 discussion with medtechs and caregivers to educate them about R1’s behavioral changes to prevent recurrences.

SP, who provided intervention during the incident between R1 and R2 no longer works at the facility and was unable to be interviewed; however, interview with R2 revealed that SP intervened by preventing R2 from being hurt by R1. R2 stated that R1 pushed them but R2 did not fall because SP stepped in and de-escalated the situation. LPA interviewed R1; however, R1 did not provide information regarding the incident.

Interviews with (5) out of (12) residents stated that they are aware that R1 is verbally aggressive sometimes, but do not feel unsafe around R1. Nine (9) out of (12) residents indicated that they feel safe living at the facility and that staff intervene appropriately when residents exhibit “aggressive” behaviors.

Review of R1’s records revealed that R1 has been receiving Hospice services and has consistent care and monitoring since September 25, 2025, to present.

Interviews and record review do not corroborate the allegation that staff retains residents whose presence poses a health and safety risk to other residents.

Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Alisa Dean, Executive Director, and a copy of this report was provided.