complaint·April 16, 2026

The investigation revealed the following: Allegation: “ Staff are not assessing residents for a higher level of care” , it is alleged that the facility is retaining residents who need higher-level of care, as many residents show signs of dementia and Alzheimer’s disease. All (4) staff interviewed denied the allegation and stated that they do not have residents with dementia or Alzheimer’s disease. Staff indicated that some of the residents may have mild cognitive impairment but can still perform their daily activities. Staff stated that they assess residents regularly for any changes in their condition. S1 stated that they know not to retain residents with dementia or Alzheimer’s disease as they require a higher level of care that the facility is licensed to provide. All (5) residents interviewed denied the allegation and stated that they are quite independent and can manage their daily tasks. Residents stated they experience memory lapses at times or have occasional forgetfulness (like misplacing items) but are aware that those are part of aging. During interviews, LPA observed that residents appeared alert and communicative. A review of (5) random physician’s reports revealed that none of the patients have been diagnosed with dementia or Alzheimer's disease. In addition, the incident reports revealed a low incident rate of falls, injuries, or changes in conditions, as well as no reports of re-occurring issues. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: “Staff are not checking on residents in a timely manner.” It is alleged that the facility often keeps residents with cognitive impairment alone in their rooms without proper supervision or care and that some residents rarely come out of their rooms. All (4) staff interviewed denied the allegation, stating they provide necessary care and supervision, have adequate staffing, including night and on-call staff and follow residents' care plans. Staff also stated they completed the necessary training, including shadowing. All (5) residents interviewed denied the allegation, praising the staff for their care and timely responses to calls using pendants or call lights. Residents stated they can handle their everyday tasks, need minimal assistance and are free to stay or leave their rooms whenever they want. During the visit, LPA pressed the resident’s call light in Room C4's bathroom to check response times, and it took staff 01:03.58 minutes to respond to the call. LPA observed the residents to be clean and interact well with staff and other residents. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: “Untrained staff providing care to residents.” It is alleged that facility regularly brings in caregivers from third-party staffing apps to fill shifts, with staff that are not properly trained and may not hold appropriate qualifications to care for residents with significant cognitive impairment. All (4) staff interviewed denied the allegation, stating that before staff are allowed to work, they must complete the required training to provide proper care to residents. Staff interviewed stated that nurse registry has been contracted to cover for staff who are out, and S1 verifies their qualifications and training. S1 indicated they also have a third party insurance company that set up a care team that includes doctors and nurse practitioners. The team visits residents who have enrolled in the program once a month, or as necessary and offers labs and x-rays to residents who choose not to leave the community. All (5) residents interviewed stated the staff have never handled them improperly or have given them the wrong medications and assist them with their personal hygien e. Staff training was reviewed and showed that care giving staff, including med techs, have the required certification and training. During the visit, LPA did not observe signs of improper care such as rough handling or poor hygiene of the residents. Incident reports were also reviewed and did not show recurrent falls, injuries or medication errors. Therefore, there is insufficient evidence to corroborate the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was held and a copy of this report was provided to Gabrielle McDonald, Administrator in training and Sister Magdalene Grace, RN, Care Coordinator.