complaint·November 19, 2025

During today’s visit, between 10AM and 10:40AM, LPA Huynh conducted a safety tour, interviewed the Administrator, one (1) staff, two (2) residents, and attempted four (4) resident interviews. Beginning at 11:09AM, the LPA conducted a medication review. No immediate concerns were observed, and medication errors were documented on a Case Management report. The following was then determined: Allegations: “Staff inappropriately restrained resident to the bed to prevent them from getting up,” “Staff are chemically restraining resident,” “Staff did not treat resident with dignity and respect,” “Staff did not provide adequate food service.” It was reported that facility Staff restrained Resident #1 (R1) to their bed physically and by utilizing sleeping aids, and do not treat Residents with respect or provide Residents meals when requested. Interview with three (3) Residents revealed that they have not experienced or observed Staff physically restrain Residents to their beds. Resident #2 (R2) stated R1 was previously their roommate and did not observe any mistreatment from the Staff. Resident #3 (R3) and Resident #4 (R4) both confirmed physical restraints have not been used on R1. Three (3) out of three (3) Residents reported that staff care is good, are respectful, and do not typically raise their voice at the Residents. R4 noted that they have experienced staff raising their voices when R4 had accidents, but Staff were instructing R4 to prevent future accidents. Additionally, Residents reported receiving meals throughout the day with R2 noting they are never left hungry. Overall, Residents had no concerns regarding staff treatment and level of care provided. Interview with the Administrator and two (2) Staff revealed that Staff do not utilize restraints or yell at the Residents. Staff #1 (S1) reported that they raise their voices occasionally when they are communicating with Residents who are hard of hearing. S1 noted that Staff try their best to accommodate Resident requests which include food services and S1 understands the importance of their role to provide care and comfort to the Residents due to their health conditions. S1 and Staff #2 (S2) assist the Residents with most of their Activities of Daily Living (ADL), which include cleaning, cooking, showering, transfers, and medication management. Report Continued on LIC 9099-C The Administrator and Staff reported that meals are served as followed: Breakfast is served between 8:30AM and 9AM or when the Residents wake up, Lunch is served between 1PM and 1:30PM, Dinner is served between 5:30PM and 6PM, and snacks are offered between each meal and upon Resident requests. Facility grocery shopping occurs twice a week and Residents receive home cooked meals. The facility’s food supply was observed to be sufficient and of good quality. Medication review revealed that Residents were prescribed sleeping aids: R1, R3, and Resident #5 (R5) were prescribed Temazepam and R4 was prescribed Trazadone with each dosage accounted for on the facility’s Medication Administration Record and Centrally Stored Medication and Destruction Record. LPA Huynh did not observe additional storage of prescribed medications or Over The Counter (OTC) medications. Resident medications are administered twice a day in the Morning and at Bedtime. Additionally, R1, R2, and R4 receive medication administration in the Afternoon. R1’s Physician’s Report dated 02/04/2024 indicated R1 was diagnosed with Huntington’s Disease, Anxiety Disorder, Depression, and Schizophrenia. R1 was documented to be Non-Ambulatory with bed bound status, minimally responsive, and required maximum assistance in all ADLs. R1’s Physician’s Report dated 03/10/2025 documented R1 to be Bedridden. Based on interviews and record review, although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency related to the allegations cited. Exit interview conducted. A copy of the report was reviewed and provided.