complaint·February 6, 2026

Interviews were conducted with thirteen staff and five residents. Five of five residents denied having any knowledge of staff forging physician signatures or altering physician orders. Three of five residents stated their facility file, and paperwork is complete to their knowledge and two of five residents stated they were unsure of what paperwork would be required. Nine of thirteen staff interviewed denied staff forging or altering physician signatures and denied having any knowledge of incomplete paperwork or delayed destruction of medication. One of thirteen staff stated they do not work with medication or resident paperwork and did not know if staff had forged or altered physician orders or signatures. Three separate attempts were made to contact three of thirteen staff, however, they could not be reached to confirm or deny allegations. Regarding allegation, Centrally stored medications are not kept in a safe and locked place, the following was revealed: Five of five residents denied the allegation and stated they have not seen any medication out of place or in common areas. Ten of thirteen staff denied the allegation and stated medication is maintained centrally stored and locked. Three separate attempts were made to contact three of thirteen staff, however, they could not be reached to confirm or deny allegation. During the course of the investigation, LPA did not observe any medication out of place or in common areas. Regarding allegation, Staff failed to report incident(s), the following was reviewed: It is alleged staff were prevented from reporting incidents, including behavioral and psychological changes, to residents’ family. During their interview, five of five residents denied the allegation and stated all incidents, including changes in their condition are reported to their responsible parties. Eight of thirteen staff interviewed stated incidents, including changes in condition, are always reported to the residents’ responsible parties and denied ever being personally instructed not to report an incident or having any knowledge of staff ever being prevented from reporting any incident. Two of thirteen staff stated they were not responsible for reporting incidents and did not know if all incidents were or are being reported. Three separate attempts were made to contact three of thirteen staff, however, they could not be reached to confirm or deny allegation. Regarding allegation, Residents have scabies, the following was reviewed: It is alleged the facility refused to admit the presence of scabies resulting in an unknown number of residents and five staff contracting scabies. Five of five residents interviewed have been residing at the facility since 2021 and denied the presence of scabies then and now. During the course of the investigation, five of five staff identified as having scabies were contacted. (Cont. LIC9099-C) Three of five staff stated they had contracted scabies while working the facility and had been provided with medical treatment by the Licensee, however, were unable to identify residents alleged to have also contracted scabies. Three separate attempts were made to contact two of five staff, however, they could not be reached to confirm or deny allegation. Regarding allegation, Staff failed to protect residents from harm, the following was revealed: It is alleged Staff 1 (S1) interacted with COVID residents and was then mandated to pass medication in the COVID-free residents. Three of five residents stated there was a division of staff working with COVID positive residents and a separate division of staff working non-COVID residents. Two of five residents denied knowing whether or not there was separation of staff working with COVID and non-COVID residents. Nine of thirteen staff interviewed denied having knowledge of alleged incident and stated there was a division of staff working with COVID residents and a separate division of staff working with non-COVID residents. One of thirteen staff stated they do not provide care to the residents and stated they did not know whether or not there was a division of staff. Three separate attempts were made to contact S1 and two additional staff, however, they could not be reached to confirm or deny allegation. Based on observations made during the course of the investigation, resident record review, and due to allegations being uncorroborated during interviews conducted, the Department is unable to determine if Staff mismanaged residents' medications, if Staff mismanaged residents' medical records, if Staff did not administer medications to residents according to physician’s orders, if Centrally stored medications were not kept in a safe and locked place, if Staff failed to report observed changes of condition, if Staff failed to report incident(s), if Residents had scabies or, if Staff failed to protect residents from harm. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.