Complaint·March 5, 2026

Regarding the Allegation : Staff did not administer medication to residents. This complaint alleged that the facility did not administer medicated to R1. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. LPA Calderon noted staff giving medications to residents in care. Records review indicate the following: reviewed MAR for residents indicates that the medication given to residents is given in the correct amount. R1 is not a resident, and no records could be found. Physician report (dated 02/23/2026) indicates that residents self-medicate. Interviews indicate the following: S1 indicates that staff follows the physician report for residents and they follow the MAR. Staff S2-S3 state that staff do not overmedicate residents. 3 of 3 staff deny the allegation. R1 could not answer any questions as residents do not exist. R2-R6 indicates that staff follow the residents MAR. 5 out of 6 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not administer medication to residents” is found to be UNSUBSTANTIATED. Regarding the Allegation : Facility does not have adequate food services. This complaint alleged that the facility did not feed residents. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. LPA Calderon noted staff cleaning the facility. LPA Calderon witnessed staff serving residents’ breakfast. LPA Calderon inspected the kitchen area and noted 2 days and 7 days of food. Records review indicate the following: Reviewed March Menu, appears well balanced meals served to residents in care. Interviews indicate the following: S1 states that the facility serves 3 meals per day and snacks. S1 indicates that no residents go hungry. 3 out of 3 staff deny the allegation. R1 could not answer any questions as R1 does not exist and does not live at the facility. 5 out of 6 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “facility does not have adequate food services” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff do not meet residents’ overall needs. This complaint alleged that the facility did not meet residents’ overall needs. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. LPA Calderon noted staff cleaning the facility. LPA Calderon witnessed staff serving residents’ breakfast. LPA Calderon witnessed activities being done in the activities room. Records review indicate the following: Reviewed the activities schedule for March 2026. Appears well balanced activities being given to residents. Interviews indicate the following: S1 states that the facility meets residents’ overall needs by giving meals, cleaning, activities and medications. 3 out of 3 staff deny the allegation. R1 could not answer any as R1 does not exist and does not live at the facility. 5 out of 6 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff is not meeting resident’s overall needs” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Robin Culver (S1).