Complaint·April 15, 2026

Regarding the allegation: Unqualified staff providing care to residents. It was alleged that S2 lacked the skills and competence to provide care and supervision to the residents. To investigate the allegations, LPA conducted interviews with two (2) staff members. LPA’s interview with S2 revealed they are the live-in staff member who cares for the residents and S1 will arrive in the mornings and evenings to assist with medications. When questioned if they could provide information regarding the residents’ diagnosis and needs/services, S2 could not answer. Additionally, upon LPA’s arrival on 4/02/2026, LPA observed S2 to be walking around the neighborhood’s curved sidewalk, away from the facility leaving all three (3) residents alone. Further record review of S2’s file revealed that S2’s First Aid/ Cardiopulmonary Resuscitation (CPR) certification was expired (01/2026). LPA’s interview with S1 revealed they would have to seek a new replacement for S2 due to them lacking the compression needed to fulfill their position. When questioned if they could provide S2’s proof of training via documentation showcasing dates and hours of training completed, S1 could not provide LPA with the information requested but instead a sheet dated 10/11/2025 with topics such as: Resident Personal Right, Elder Abuse and Hand washing and Infection Control. The documentation provided documented the length of training to be “2.5 hours”. When questioned where the remainder of S2’s training hours were reflected via documentation showcasing dates and hours of training completed, again S1 could not provide LPA with the information requested. Based on interviews, observations and record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Regarding the allegation: Facility does not have adequate staffing. It was alleged that the facility had failed to provide an appropriate level of supervision to ensure resident’s needs are met. To investigate the allegation, LPA conducted interviews with two (2) staff members. LPA’s interview with S1 revealed they arrive both mornings and evenings to assist with residents’ medications. When questioned if they could provide the LIC 500 Personnel Report showcasing staff and their schedule, S1 could not provide LPA with the information requested. LPA’s interview with S2 confirmed they are the only staff member working. S2 stated they receive, “No Breaks”. Additionally, upon LPA’s arrival on 4/02/2026, LPA observed S2 to be walking around the neighborhood’s curved sidewalk, away from the facility leaving all three (3) residents alone. During LPA’s initial visit, LPA observed R3 to call out for assistance from their room while both S1 and S2 were in the kitchen. LPA observed S1 to tell S2 to go assist R3. During LPA’s physical plant tour, LPA observed R3’s bedroom to not have any auditory alarms to communicate when they need assistance. LPA’s interview with S1 revealed they have not placed such alarms yet but would. (Continue to LIC 9099-C) Based on interviews, record review and observations, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Citations issued, please refer to LIC 9099-D. No other immediate health and safety issues observed during the day of the visit. Exit interview was conducted, appeal rights given, and a copy of this report was provided to the Administrator. Regarding the allegation: Staff are mismanaging resident’s medication. It was alleged that facility are withholding R1’s medication. To investigate the allegation, LPA attempted interviews with three (3) residents and two (2) staff members. LPA’s interview with R1 revealed they only care to take two (2) of their medications due to them not knowing what their other medications are for. R1 stated that both S1 and S2 do not give them their medication upon their request and keep their medications locked away with the other residents. R1 stated they can manage their own medication. LPA’s interview with R2 revealed that they have had no issues with their medications being given to them. LPA attempted to interview R3 but due to their inability to validate the questions being asked, LPA terminated the interview. LPA’s interview with S1 revealed that they follow the physician’s orders of R1’s medication and R1 will argue that they need more. S1 stated they were not aware of R1’s addiction to their medication upon their arrival to the facility. S1 stated they have tried to have R1 see their primary doctor but R1 refuses to go. LPA conducted a record review of R1’s medication. The medication in question was reviewed and compared to the Medication Administration Records (MARs) from 3/1/2026 to 4/01/2026. LPA observed the physician’s orders to be prescribed as needed (PRN) and ordered to, “Take 1 tablet by mouth twice daily as needed for pain. May take an additional 1 for breakthrough”. LPA observed R1’s MARs to have morning, afternoon and evening listed for their medication pass. Additional record review of R1’s Physician’s Report documented that they could not store their own medication and needed “supervision” with medication administration. LPA’s supplementary web search on 4/08/2026 of said medication was reviewed to be, “…a controlled substance (Schedule II) with high risk of addiction, dependency…” Further record review of R1’s medication in question was filled on 3/13/2026 and was observed to have been prescribed for a quantity of 75 pills. LPA’s medication count conducted with S1 observed there to be a remainder of 38 pills accounted for. LPA’s review of R1’s MARs (3/13/2026 to 4/01/2026) accounted for 35 pills administered. R1’s medication was not documented as taken for the afternoon and evening of 4/01/2026. R1’s medication was not documented as taken for the morning of 4/02/2026. During LPA’s physical plant tour, LPA observed R1’s medication to be centrally stored within the locked medication cabinet. LPA did not observe any discrepancy of R1’s medication. Based on interviews, record review and observation there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Facility is in violation of Fire Safety regulations. It was alleged that the fire alarm pull station was not functioning. To investigate the allegation, LPA conducted a physical plant tour. LPA observed two (2) fire extinguishers to be fully charged and dated 5/29/2025. LPA observed the fire alarms to be interconnected. LPA along with S1 tested the alarms where LPA observed the alarms to be working and in proper condition. LPA observed the carbon monoxide to be in proper condition. LPA along with S1 tested the carbon monoxide and observed it to be working. LPA observed the fire alarm pull station to be intact with business cards located on top of the alarm with electrical contractor’s information. Additional record review of the facility’s Emergency Disaster Plan revealed S1 had reviewed and updated the plan on 2/14/2026. LPA reviewed the plan to entail emergency names and telephone numbers such as: Fire Department and Ambulance/Paramedics. Based on observations and record review, the facility’s fire alarms/carbon monoxide and fire extinguishers were observed to be working and in proper condition. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure facility was kept clean, safe and sanitary. It was alleged the facility did not have adequate pest control. To investigate the allegation, LPA conducted interviews with two (2) residents and one (1) staff member. LPA’s interview with both residents confirmed the facility has not had any issues with pest such as roaches or rats. During LPA’s physical plant tour, LPA observed the facility to be in proper condition. LPA did not observe any pest. However, LPA did observe R1’s bedroom to appear unorganized with an odor omitting from said quarters. LPA’s interview with R1 revealed they do not like the staff entering their room nor do they allow the staff to clean their room. LPA’s interview with R2 correlated R1’s interview. LPA’s interview with S1 confirmed R1 has made it difficult for staff to clean and maintain R1’s bedroom within compliance. Based on interviews and observations, the facility was not observed to have any pest and R1’s confirmation of not allowing staff to clean their room, therefore the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.