Complaint·March 23, 2026

The investigation revealed the following: Allegation 1: Staff do not ensure medication cabinets remain locked at all times. At 11:05 AM, LPA toured the facility and the medication storage area and LPA observed that the medications were locked in the kitchen area and the locks consisted of a combination lock and magnetic lock on the cabinet and locked storage medication boxes inside the cabinet. LPA attempted to interview R1-R2 and they could not engage in a conversation. LPA did conduct interviews with R3-R5, and 3 out of 5 stated that the medications are brought to them and not sure if the cabinet is locked or not. LPA also conducted interviews with staff member 1-2 (S1-S2) and they were asked does all the staff ensure that the medication cabinets always remain locked and 2 out of 2 staff stated cabinets are always locked unless they are passing medications and no one has access to the kitchen area but the staff. Allegation 2: Staff do not ensure residents medications are properly managed LPA attempted to interview R1-R2 and they could not engage in a conversation. LPA did conduct interviews with R3-R5, and they stated that they believe that their medications are managed properly. LPA conducted interviews with staff member 1-2 (S1-S2) and they were asked does all the staff ensure residents medications are properly managed and 2 out of 2 staff members stated the residents are managed properly and documentation is noted daily. Allegation 3: Staff do not follow residents dietary care plans LPA attempted to interview R1-R2 and they could not engage in a conversation. LPA did conduct interviews with R3-R5 and 3 out of 5 stated their dietary care plans are followed. During LPA visit LPA observed that the residents were being provided lunch based on their care plans and dietary needs. LPA conducted interviews with staff member 1-2 (S1-S2) and 2 out of 2 staff members stated the staff does follow the residents’ dietary care plans . continued Based on interviews, file review and observation during the investigation, the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Paige Esquivel-House Manager at the conclusion of the visit. Allegation 4: Licensee is not addressing issue with pets in the facility LPA attempted to interview R1-R2 and they could not engage in a conversation. LPA did conduct interviews with R3-R5 and 3 out of 5 stated there are no animals at the facility. LPA conducted interviews with staff member 1-2 (S1-S2) and 2 out of 2 staff members stated there are no pets in the home other than the fish. Allegation 5: Staff does not ensure residents personal items are safely secured LPA attempted to interview R1-R2 and they could not engage in a conversation. LPA did conduct interviews with R3-R5 and 3 out of 5 stated they are in possession of their personal items and that they are safely secure. LPA conducted interviews with staff member 1-2 (S1-S2) and 2 out of 2 staff members stated residents’ personal items are safely secure, and their names are written on their clothes and if someone happens to get another resident’s personal item(s) it is returned to the owner. Allegation 6: Staff do not ensure residents care needs are properly assessed LPA attempted to interview R1-R2 and they could not engage in a conversation. LPA did conduct interviews with R3-R5 and 3 out of 5 stated their needs are taken care of by the staff and they receive what they need. LPA conducted interviews with staff member 1-2 (S1-S2) and 2 out of 2 staff members stated residents’ personal care needs are met daily based on their needs and service plan. During LPA visit LPA observed that the medications were locked in the kitchen area inaccessible to the residents in care. LPA also reviewed the medication administration records (MARs) and it appeared that the residents medications are being provided as prescribed by their physician and managed properly, LPA also observed the residents dietary needs were being met during lunch based on their care plans, LPA did not observe any animals inside the facility cats/dogs/pets other than fish at the time of visit, and during the tour of the facility it appeared that the residents had their personal items in their possession stored in their bedrooms. Continued