complaint·February 19, 2026

Regarding the allegation, Staff did not seek medical attention for resident , it is alleged that staff did not seek medical attention in a timely manner for R2. Five out of five facility staff denied the allegation, stating R2 that emergency services were called promptly when R2 reported chest pain and difficulty breathing. The resident was transported to the hospital, and passed away there thre days later. During an interview conducted, R2’s family/Witness 2 (W2) denied the allegation, stating that they believe the facility contacted emergency services timely and do not suspect any delay in response. Based on Hospital Discharge records dated June 4 2025, R2 passed away on May 31, 2025 due to a preexisting condition. Regarding the allegation, Facility failed to safeguard resident’s personal items , it is alleged that staff did not safeguard Resident 1’s personal belongings by removing and/or disposing of residents’ cooking appliances, cookware, refrigerator, vegan food items, cash, and additional personal items without residents’ consent on September 12, 2025. LPA conducted interviews with Resident 1 (R1), Witness 1 (W1), four additional residents, and five staff. During the course of the investigation, R1 and W1 provided LPA with a list of personal belongings that were reported to have been removed from R1’s room by staff on September 12, 2025, without R1’s consent. Based on records reviewed, the facility provided all residents with notice on two separate occasions, that rooms would be inspected and hazardous items and items that may create a risk to residents’ health and safety, would be removed. Five out of five facility staff interviewed, denied the allegation, stating that R1 was present during the inspection of the room, the room required deep cleaning due to unsanitary conditions including: scattered and rotten food, and soiled carpet damage, which posed an immediate risk to R1 and roommate. When interviewed, R1 was not able to provide proof that cash on list provided, was in the R1’s room on September 12, 2025 and removed by staff. Personal property on R1’s list, including cash, was not inventoried upon admission, as per the Resident Personal Property and Valuables (LIC621). LPA conducted a follow-up interview with R1 and it was confirmed that the LIC621 was not completed or updated by the resident upon or after admission. R1 stated they started to bring in more items that were hard to track and notify the facility about the existence of such items.During a walk though of R1’s room, LPA observed R1’s room, the room was found unorganized and unsanitary with unwrapped food on the table and gnats flying around the uncovered food. Based on LPA’s observations, the uncovered food had been sitting on the table for several hours or longer. The refrigerator was observed in unsanitary condition with 3-4 spills in different areas inside, that had not been wiped/cleaned, and there were multiple food items inside the refrigerator with mold growing on them. LPA also observed perishable and non-perishable food items in R1s room that were past the expiration date. Photos were taken. Additionally, four out of five residents interviewed denied the allegation and confirmed that the facility provided all residents with notice on two separate occasions, indicating hazardous items and items that may create a risk to residents’ health and safety would be removed from their rooms. Regarding the allegation, Staff did not notify resident of changing rooms , it is alleged that staff did not give R1 advanced notice of room change from #286 to #287 on September 12, 2025. Record review of R1’s Admission Agreement signed on December 30, 2024, 12. Room Change Notification states the resident will be notified 30 days in advance of room change “unless …necessary due to any emergency.” Five out of five staff interviewed stated R1’s room was in such unsanitary conditions, including the soiled carpet, that there was an emergent need to relocate R1 and roommate to the neighboring room (Room #287) without advanced notice. Room# 287 had been previously remolded, with newly finished hard wood floors. During interview, R1 stated they would prefer to remain in Room #287, even after renovations are completed on Room #286, where they previously resided. Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, 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 following allegations, Staff did not seek medical attention for resident, Staff did not safeguard resident’s personal belongings, and Staff did not notify resident of changing room, are deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Ephantus Warui, and a copy of this report was provided at exit.