complaint·January 26, 2026

Interviews with three of four staff revealed that narcotics are destroyed by two staff members and that they keep a destruction log at the facility. Two of four staff informed LPA that if the resident is on hospice, the LVN will destroy the medications before leaving the facility. One of four staff informed LPA that they have never destroyed medications at the facility due to their position. LPA observed a destruction of medication list for Resident#1 (R1) dated December 10, 2025 for two controlled substances that were destroyed by a hospice care nurse as well as a disposal lists for R1 and Resident #2 (R2) with two staff signatures on every entry during their stay at the facility until they left the facility. Therefore, the facility allegation of narcotics are not properly destroyed has been deemed UNFOUNDED. Regarding the allegation of Staff are not properly trained revealed the following: It was alleged that staff had not been trained on how to assist residents with transferring from a wheelchair. LPA observed an in service training dated July 2, 2025, covering topics of postural supports and caring for residents with dementia. LPA conducted interviews with residents and two of three residents were unable to confirm or deny if they have been injured due to staff assisting them in and out of their wheelchair. LPA observed faint bruising on two of three residents arms where the wheelchair lines up. LPA observed two of three residents fidgeting with their wheelchair and their arms hitting the wheelchair where the faint bruising was observed. Therefore, the facility allegation of Staff are not properly trained has been deemed UNFOUNDED. Regarding the allegation of Facility did not have sufficient food revealed the following: LPA observed the kitchen and pantry to have more than a two day perishable and seven day nonperishable food supply on hand. Interviews with four of four staff revealed that the facility has not had any issues with the food supply. One of three residents informed LPA that they get enough to eat and has not had a problem with getting food. Two of three residents were unable to confirm or deny the allegation. Therefore, the facility allegation of Facility did not have sufficient food has been deemed UNFOUNDED. Regarding the allegation of Facility staff are not following infection control practices revealed the following: It was alleged that staff are not disposing of their gloves before assisting in the dining room and kitchen. LPA observed the facility infection control plan that states facility staff are to perform hand hygiene before and after assisting residents with medications, food or assisting with bodily fluids. Four of four staff informed LPA that they are trained to take the gloves that are being used to assist residents off in the same room or bathroom that they are assisting the resident in. Continue on LIC9099C Four of four staff informed LPA that they are to dispose of the gloves, wash their hands and sanitize before moving on to prevent cross contamination in the facility. Three of four staff informed LPA that they are to not wear gloves in the facility hallways to ensure that they are following infection procedures. One of three residents informed LPA that staff are always sanitary. Two of three residents were unable to confirm or deny the allegation. LPA did not observe staff with gloves on outside of resident rooms or bathrooms. LPA observed an in service training dated February 6, 2025, and May 1, 2025, regarding facility protocols and infection control. Therefore, the allegation of Facility staff are not following infection control practices has been deemed UNFOUNDED. Regarding the allegation of Facility did not meet the residents’ needs revealed the following: It was alleged that staff are not hydrating residents as well as not providing a Hoyer lift for R2 causing them to be left soiled for an extended period of time. LPA observed an in service training dated August 27, 2025, covering topics of hydration and feeding. LPA observed a water dispenser for resident use in the facility lobby. LPA observed residents use the water dispenser for hydration needs. LPA observed staff filing cups and giving them to residents as needed. LPA observed a Patient Information Packet from Motion Complex Rehab rental agreement for a Hoyer lift and solid sling for R2. LPA observed a delivery ticket from Motion Complex Rehab dated December 2, 2025, stating that the lift had been delivered to the facility address. LPA interviewed residents and one of three residents informed LPA that all of their needs are taken care of. Two of three residents were unable to confirm or deny the allegation. Therefore, the allegation of Facility staff did not meet the resident’s needs has been deemed UNFOUNDED. The Department has investigated the above mentioned complaint allegations and based on observations, interviews and records reviewed, the above allegations have been deemed UNFOUNDED. This means that the allegations are false, could not have happened and/or is without a reasonable basis. The Department therefore has dismissed the complaint. An exit interview was conducted and a copy of this report was left at the facility. Upon interviews with staff it was revealed that one of four staff informed LPA that the staffing has improved but could be better. One of four staff informed LPA that the facility has been good with staffing and the residents needs are being met. One of four staff informed LPA that they are able to cover the shifts of the individuals that call out to ensure there is staff present to meet the residents needs. Upon interviews with one of three residents it was revealed that staff assist them and their needs are all met. Two of three residents could not confirm or deny the allegation. Although the above allegation may have happened there is not a preponderance of evidence to prove the alleged violation occurred; therefore the allegation facility did not ensure adequate staffing is deemed UNSUBSTANTIATED. Therefore, the Department dismisses the allegations. An exit interview was conducted and a copy of this report was left at the facility.