complaint·September 13, 2025

Regarding the allegation: Staff did not administer medication as prescribed resulting in death. It was alleged that S2 did not administer R1’s medication accordingly resulting in death. To investigate the allegation, LPA attempted interviews with four (4) staff members and conducted a record review of R1’s medical records. LPA’s interview with three staff members stated that they have not witnessed nor heard of any residents being over-medicated. LPA attempted to interview S2 but S2 was on leave and could not be contacted. LPA’s record review of R1’s Centrally Stored Destruction Medication Record (CSDMR) noted that on 7/25/2024 (the day prior to R1’s passing) R1 was not assisted with medication by S2. Further review showcased that S2 had not assisted R1 with their medication since 7/19/2024. LPA’s review of S2’s file revealed that S2 had been demoted at the end of July 2024 from Medication Technician (Med Tech) to Care Partner due to various disciplinary incidents, however, no medication errors were documented. Further review of R1’s medical record revealed that R1 had been placed under the care of Caremark Healthcare Hospice services from 7/02/2024 to 7/26/2024, following a medical diagnosis of terminal illness with a life expectancy of less than six months. Additionally, R1’s Certificate of Death listed R1’s leading cause of death to be a result of Cardiopulmonary Arrest. Also, R1’s decline of health was documented during various visits from hospice care. On 7/23/2024 the Hospice service visit documented, R1 was observed to be within their, “…transitioning” period. Based on interviews and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not prevent the facility from being unsanitary. It was alleged that the facility’s kitchen and bathrooms are left in unsanitary conditions. To investigate the allegation, LPA attempted interviews with ten (10) residents and four (4) staff members. LPA’s interview with nine (9) out of the ten (10) residents revealed that they have not seen the bathrooms dirty. Interview with R3 stated that the bathrooms, “…are cleaned regularly”. LPA attempted to interview R11 but they declined to be interviewed. LPA’s interview with S1 and S7 confirmed that the bathrooms are cleaned daily. Interview with S7 revealed that the bathrooms are cleaned throughout each shift and if, “…there is an accident, they call us and we take care of it”. Regarding the kitchen, LPA’s interview with S6 revealed the kitchen is cleaned… “every day… multiple times a day”. LPA’s record review of the Kitchen’s Daily Cleaning Schedule confirmed a morning and night schedule of various cleaning tasks kept and documented. During LPA’s physical plant tour, LPA observed all publicly accessible bathrooms to be clean and in sanitary conditions. (Continue to LIC 9099-C) During LPA’s observation of the kitchen, LPA observed the kitchen to be clean and free from pests. LPA observed kitchen staff washing pots and dishes after use. LPA observed the stove and kitchen appliances to be clean and in proper condition. Based on interviews, record review and observation, the facility’s bathrooms and kitchen were observed to be in sanitary conditions. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are serving uncooked foods to residents. It was alleged that staff are serving uncooked food to residents. To investigate the allegation, LPA interviewed nine (9) residents and four (4) staff members. LPA’s interview with all residents revealed that they have never been served uncooked meat by staff. LPA’s interview with R6 revealed that they have never been served uncooked meat and that, “…the food is delicious”. LPA’s interview with S9 revealed that the meat is checked with a cooking thermometer to ensure the meat has reached a safe and desired temperature prior to being served to the residents. During LPA’s physical plant tour, LPA observed a cooking thermometer and kitchen appliances to be in proper working conditions. LPA observed food preparation stations to be clean. LPA observed a variety of food being prepared for consumption. LPA observed the food being served to be edible and not appear uncooked. Based on interviews and observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Community Sales Director. Regarding the allegation: Staff did not ensure that dishes are cleaned. It was alleged that the facility’s ice machine and dishes served to residents are not cleaned. To investigate the allegation, LPA conducted a physical plant tour of the kitchen, LPA observed a variety of dishes and utensils to be clean and washed properly. In the dining room, LPA observed a variety of plates, utensils and cups to be clean and in sanitary conditions. However, during LPA’s review of the facility’s Ice Machine Cleaning Log, it was revealed that the cleaning of the ice machine had not been documented since April of 2025. LPA’s interview with S8 stated that the ice machine is to be, “cleaned monthly but it hasn’t been cleaned…”. Based on interviews, observation and record review, the facility has failed to keep the ice machine properly clean, therefore the allegation is SUBSTANTIATED at this time. Citation issued, please refer to 9099-D. No other immediate health and safety hazards observed during the time of the visit. Exit interview conducted, Appeal Rights given, and a copy of this report was provided to the Community Sales Director.