Complaint·July 23, 2025

outside. Based on records review and interviews, the allegation Staff do not ensure residents needs are met is undetermined if this allegation is valid. LPA reviewed shower and incontinence schedule showing how often residents are showering and being changed. Residents are being showered and changed regularly. Interviews indicate residents are being showered and changed regularly. Based on interviews, the allegation Staff do not ensure residents personal property is safely secured it is undetermined if this allegation is valid. Administrator does not have any reports of any property being stolen. Administrator has had issues with residents thinking a shirt is theirs because several residents have white shirts that are similar or the same. Administrator stated she started writing the name on the shirt tags to prevent confusion. Facility rooms all have locks on doors, so residents are able to lock rooms to prevent others from going in their rooms. Based on interviews, the allegation Staff do not ensure adequate care and supervision is provided resulting in resident elopement, it is undetermined if this allegation is valid. Interviews indicate facility has not had any elopements that have not been addressed. Prior to this complaint, Administrator stated the last elopement was in January 2025. Based on records review and interviews, the allegation Licensee does not ensure fire drills are conducted in the facility is undetermined if this allegation is valid. Facility records show disaster/fire drills were conducted 1/2025, 2/2025 and 5/2025. Administrator stated drills are conducted regularly. LPA obtained copies of drills with staff signatures showing completed. Based on interviews, observation and records review, the allegation Staff does not ensure sufficient activities are provided for residents in care in undetermined if the allegation is valid. LPA observed a calendar in the dining room showing daily activities. LPA observed residents playing bingo, watching movies, listening to music and doing exercises during visits at the facility. Based on records review, observation and interviews, it is undetermined whether or not the allegations occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report was provided to Administrator.