Complaint·October 28, 2025

Regarding the Allegation : Staff do not follow proper procedures when lifting residents. This complaint alleged that the facility did not use the Hoyer lift to move residents from bed to wheelchair. LPA Calderon toured the facility with S1 and did not note any negative interaction between staff and residents. LPA Calderon noted staff giving morning medications to residents. Records review indicate the following: Hoyer Lift training was reviewed. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 was taken to the hospital on 10/27/2025 for heart issues and could not be interviewed. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are not following proper procedures when lifting resident” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not ensuring that residents are being provided with food of sufficient quality. This complaint alleged that the facility staff did not provide food for residents to eat. LPA Calderon toured the facility with S1 and did not note any negative interaction between staff and residents. LPA Calderon noted weekly menu and diabetic menu for R1. LPA Calderon noted 2 days and 7-day supply of food. Records indicate the following: reviewed text messages between staff and R1 conservator. Text indicate that staff had communicated with conservator meals being provided to R1. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 was taken to the hospital on 10/27/2025 and could not be interviewed. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not ensuring that resident is being provided food of sufficient quality” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff do not ensure that residents are provided with an adequate amount of liquids. This complaint alleged that the facility staff did not provide liquids for residents to drink. LPA Calderon toured the facility with S1 and did not note any negative interaction between staff and residents. LPA Calderon inspected the kitchen and noted juice, water and other liquids for residents to drink. Records indicate the following: Reviewed text messages between staff and R1 conservator. Text indicate that staff had communicated with conservator regarding liquids being provided to R1. Reviewed menu for facility and liquids are offered to residents. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 was taken to the hospital due to heart issues on 10/27/2025 and could not be interviewed. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff do not ensure that resident is being provided an adequate amount of liquids” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff do not assist residents with eating as necessary. This complaint alleged that the facility staff did not help R1 eat food provided by the facility. LPA Calderon toured the facility with S1 and did not note any negative interaction between staff and residents. LPA Calderon noted staff provided food for residents. Reviewed text messages between staff and R1 conservator. Text indicate that staff had communicated with conservator regarding food being served to R1. LPA Calderon did not see any residents needing help eating food. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 was taken to the hospital due to heart issues on 10/27/2025 and could not be interviewed. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff do not assist resident with eating as necessary.” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not ensuring that resident is taking their medications as necessary. This complaint alleged that the facility staff did not give R1 medication. LPA Calderon toured the facility with S1. LPA Calderon noted staff providing medications to residents. Records indicate the following: LPA Calderon reviewed Medication Administration Record (MAR) for 08/2025 to 10/2025. Appears staff provided medication daily. LPA Calderon did not notice staff missing medication for R1. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 was taken to the hospital for heart issues on 10/27/2025 and could not be interviewed. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not ensuring that resident is taking their medications as necessary” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not ensuring that residents have an operative wheelchair. This complaint alleged that the R1 wheelchair does not work. LPA Calderon toured the facility with S1 and noted that R1 wheelchair was in the living room area. LPA Calderon inspected the wheelchair for R1. LPA Calderon did not see any issues with R1 wheelchair. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 was taken to the hospital for heart issues on 10/27/2025 and could not be interviewed. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not ensuring that resident has an operative wheelchair” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not ensuring that residents attend their medical appointments as necessary. This complaint alleged that the facility staff did not make doctor appointments for R1. LPA Calderon toured the facility with S1 and did not note any negative interaction between staff and residents. Records indicate the following: Reviewed text messages between staff and R1 conservator. Text indicate that staff had communicated with conservator and advised when doctors’ appointments were made and cancelled. Reviewed Incident Report (dated 10/28/2025) report indicates that R1 appointments were cancelled for various reasons and that R1 family member was advised. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 was taken to the hospital for heart issues on 10/27/2025 and could not be interviewed. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not ensure that resident attends their medical appointments as necessary” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff handle residents in a rough manner. This complaint alleged that the facility staff handled R1 in a rough manner when moving R1 from bed to wheelchair. LPA Calderon toured the facility with S1 and did not note any negative interaction between staff and residents. Records indicate the following: Reviewed Hoyer Lift training for staff. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 was taken to the hospital for heart issues on 10/28/2025 and could not be interviewed. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff handle resident in a rough manner” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Trisha DeCampo (S1).