complaint·February 6, 2026

(Cont from 9099A) Interview with S2 reveal was assisting resident #3 (R3) in their room when resident #2 (R2) opened door by accident and immediately apologized for opening the wrong door. Staff reveal R3 did not get into R3 bed nor did R3 scream and run out of their room. Interview with administrator revealed follow-up was conducted with R2 who admitted to having a beverage containing alcohol prior to coming back to the facility and heading to their room. Administrator also stated supervision is not one-on-one, but staff are present in facility providing supervision. Interview with R3 revealed that they opened the wrong door on the way to their room but denied getting into R3’s bed. LPA was unable to interview R3 as residents no longer reside at the facility. A review of R3’s physician’s report notes mild cognitive impairment however R3 assessment notes independent and ambulates independently. Based on the information obtained from interviews and record review, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Staff do not observe changes in resident health conditions It is alleged that staff do not observe changes in resident health. Interview with administrator revealed that residents are observed by staff during regular interactions and medical attention is provided when requested or needed. Administrator also revealed that R3 no longer resides at the facility due to them experiencing various changes in behavior and/or health and required higher level of care. Interviews with three (3) out of three (3) staff reveal records are noted and LIC 624’s are sent to Licensing when changes occur in the residents’ health/behavior, or they require hospital transport. Review of LIC 624s verify that staff are documenting and observing changes in residents. LPA Smith observed staff checking on resident in lobby. Based on interviews, record review, and observation, this allegation is deemed Unsubstantiated at this time. Exit Interview conducted/Copy of report given. (cont from 9099) and staff schedule reveal the following: Three (3) caregivers on the AM shift (6:00 - 2:00 pm), three (3) caregivers on the PM shift (2:00 - 10:00 pm), and three (3) caregivers on the NOC shift (1000 pm - 6:00 am) Review of personnel report dated from July 2025 shows a total of 10 caregivers assigned and personnel report from Aug 2025 shows a total of 11 caregivers. According to the administrator, they currently have a staffing ratio of 4 caregivers on the AM shift, 3 caregivers on the PM shift and 3 caregivers on the NOC shift. However during complaint visit on 01/11/26 there were only two (2) staff available to provide assistance to residents and at least one (1) resident requires a two (2) person assistance with Activities of Daily Living (ADL s), such as bathing and toileting. I nterview with two (2) staff reveal have informed licensee of additional staff needs. Based on the information obtained, there is enough information to verify the allegation, therefore the allegation is SUBSTANTIATED at this time.