Complaint·April 23, 2026

The investigation revealed the following: Allegation – Questionable death. It was alleged that Resident #1 (R1) died from an infection a week later that she sustained from not removing or cleaning her dentures. LPA interviewed staff regarding this allegation. Staff who had remembered R1 stated that R1 resided in the assisted living side. Staff stated that R1 went to the hospital in November 2024 due to a cough and did not return to the facility. R1 was discharged from the facility on 11/25/2024. LPA obtained and reviewed the death certificate for R1. R1 passed away several months later at a different facility, and the cause of death was due to respiratory distress, congestive heart failure, and Alzheimer’s Dementia. Since R1 was not under the care of the facility during the time of death, the allegation is deemed unsubstantiated. Allegation - Staff did not take precautions to prevent a scabies outbreak. It was alleged that the facility had an outbreak of scabies around November 2025. LPA interviewed eight (8) staff, and they did not recall any outbreak of scabies at the facility. Staff stated that there was only one individual who came from the hospital and was treated for scabies. Staff took measures to prevent the spread of scabies by wearing proper PPE supplies and cleaning and disinfecting the impacted areas. Staff also redirected the resident back to the room or distanced other residents to avoid contact. Staff stated that they received training on infection control for any outbreaks and always take precautions to prevent the spread of contagious diseases. Allegation - Staff did not provide residents with self-care products. It was alleged that the facility is constantly short on supplies such as incontinence supplies and hygiene supplies like shampoo and conditioner. Staff interviewed stated that the facility has extra supplies of incontinence products and shampoo, conditioner, body wash, and soap. The facility has never run out of any of the supplies, and staff would order them before they run out. Staff stated that most of the residents’ responsible parties purchase their briefs/pull-ups, including hygiene supplies for the residents. LPA interviewed eight (8) residents. Seven (7) out of eight (8) indicated that their family members purchase and bring their incontinence and hygiene products to them. Residents have never run out of supplies. Allegation - Staff did not ensure that residents had access to their prosthetic teeth. It was alleged that residents went out without their dentures because staff could not find the keys to the closet where the dentures are stored. Per the staff interviewed, the caregivers store and clean the residents’ dentures daily. The staff put them in the storage container for cleaning at night. Staff stated that some residents can manage their own dentures and do not need staff assistance. For those who need assistance, the staff will clean the dentures and place them either in the residents’ rooms or a med cart. Staff interviewed do not recall any residents not wearing their dentures due to misplacing them or not being able to access the locked drawer. The residents interviewed did not wear dentures or did not need staff assistance with dental care. Allegation - Staff do not follow reporting requirements. LPA interviewed eight (8) staff for this allegation. The alleged unreported incidents were the death of a resident, the scabies outbreak, or a lockdown by the health department due to a water issue. Based on interviews and record review, the incidents indicated did not occur at the facility, so licensing would not be informed. Staff stated that they would report any outbreaks to the proper agencies and Community Care Licensing. In addition, the facility would submit incident reports regarding death, hospitalization, and any unusual incidents involving the residents. LPA observed that the facility has been consistently submitting incident reports to licensing for review. 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. An exit interview was conducted with the Administrator. A copy of this report, along with the appeal rights, was provided.