complaint·August 7, 2025

The investigation consisted of the following: On 07/30/2025, interviews were conducted, and facility records were gathered. Staff 1 (S1) to Staff 8 (S8) were interviewed. On 08/04/2025, interviews were conducted, and a tour of the facility was conducted. Witness 1 (W1) and Resident 1 (R1) to Resident 11 (R11) were interviewed. A tour of the facility consisted of observation of lunch time. On 08/06/2025, interviews were conducted, a tour of the facility was conducted, and records were reviewed. Interviews conducted consisted of: Resident 12 (R12), Staff 7 (S7), Staff 9 (S9), and Staff 10 (S10). A tour of the facility consisted of the kitchen and activity room. Records reviewed consisted of 9 resident medications along with their Medication Administration Records (MARs). On 08/07/2025, interviews were conducted, and records were reviewed. Witness 2 (W2) to Witness 8 (W8) and Staff 11 (S11) to Staff (12) were interviewed. Resident, staff, and facility records were reviewed. Investigation revealed the following: Allegation: “Staff left resident on floor soiled for an extended period of time”, it is being alleged that a resident fell at night and was found the next morning. Interviews conducted with R1 to R12 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S12 revealed the following: 12 out of 12 staff denied the allegation. Interviews conducted with W1 to W8 revealed the following: 8 out of 8 witnesses denied the allegation. Based on the department’s interviews this allegation is unsubstantiated. 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. Allegation: “Staff mismanages residents’ medication logs”, it is being alleged that facility staff hides, destroys, removes medication and medication documentation. Interviews conducted with R1 to R12 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S12 revealed the following: 12 out of 12 staff denied the allegation. Interviews conducted with W1 to W8 revealed the following: 8 out of 8 witnesses denied the allegation. On 08/06/2025, records reviewed and observations of 9 resident medications along with their MARs revealed the following: 9 out of 9 resident medications along with their MARs were in compliance. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. 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. Allegation: “Staff does not follow residents’ food diet.” Interviews conducted with R1 to R12 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S12 revealed the following: 12 out of 12 staff denied the allegation. Interviews conducted with W1 to W8 revealed the following: 8 out of 8 witnesses denied the allegation. Observations of lunch time on 08/04/2025 revealed the following: residents were being provided with their specialized diet. Each dining room table has diet cards for each resident. Diet cards consist of residents’ name, room number and diet (an example of a diet can be mechanical soft, thick liquids, no fish, allergic to peanuts, regular diet, etc.). Observations and records reviewed of the kitchen on 08/06/2025 revealed the following: The kitchen has diet slips and resident roster with their diet description posted on the wall. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. 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. Allegation: “Staff serves expired foods”, it is being alleged that staff served expired food and unsafe food. Interviews conducted with R1 to R12 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S12 revealed the following: 12 out of 12 staff denied the allegation. Interviews conducted with W1 to W8 revealed the following: 8 out of 8 witnesses denied the allegation. Observations of lunch time on 08/04/2025 revealed the following: no unsafe nor expired food were provided to residents. Observations of the kitchen on 08/06/2025 revealed the following: no unsafe nor expired food were observed in the freezers, fridges, or pantry. Record reviewed of Dietary Quality Control Survey dated 06/16/2025 revealed the following: the facility received an 84% score. Record reviewed of Dietary Quality Control Survey dated 07/01/2025 revealed the following: the facility received an 87% score and no mention of expired food. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. 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. Allegation: “Staff does not communicate with residents’ responsible party.” Interviews conducted with R1 to R12 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S12 revealed the following: 12 out of 12 staff denied the allegation. Interviews conducted with W1 to W8 revealed the following: 8 out of 8 witnesses denied the allegation. Records reviewed of 2025 Unusual Incident Reports (UIRs) demonstrate a history of facility contacting residents’ responsible party. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. 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. Allegation: “Staff does not ensure a safe and healthy environment for residents”, it is being alleged that residents are not receiving care and supervision. Interviews conducted with R1 to R12 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S12 revealed the following: 12 out of 12 staff denied the allegation. Interviews conducted with W1 to W8 revealed the following: 8 out of 8 witnesses denied the allegation. Observations on 07/30/2025, 08/04/2025, and 08/06/2025 revealed that residents are receiving care and supervision. Records reviewed of Employee Schedules from April 2025 to July 2025 revealed the following: the facility has staff from Monday to Friday 24 hours a day. Medical Technicians and Caregivers staff are on facility grounds 24 hours a day. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. 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. Allegation: “Staff vapes inside the facility.” Interviews conducted with R1 to R12 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S12 revealed the following: 12 out of 12 staff denied the allegation. Interviews conducted with W1 to W8 revealed the following: 8 out of 8 witnesses denied the allegation. Records reviewed of Drug Free Workplace Policy revealed the following: staff are not to use controlled substances as it affects the workplace. Observations on 07/30/2025, 08/04/2025, and 08/06/2025 revealed the following: there were no staff vaping/smoking inside the facility. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. 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. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator, Heather Argueta.