complaint·February 12, 2026

Lack of staffing/supervision Interviews conducted with Staff Members S1, S2, S3 and S4 indicated that care is being provided adequately to all residents in care. It was indicated that staffing is increasing and overall care is easier to manage with the current number of staff. S1, S2, and S3 indicated that they would like one more staff on the floor for the morning AM shift but are able to still complete all tasks assigned. Records reviewed indicated that there are staff on each shift to assist the residents in care and staff schedule indicates an increase in staff over the last few months. Therefore, the allegation inadequate staffing to provide care is unsubstantiated. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Lack of hygiene supplies Interviews conducted indicated that there are plenty of hygiene supplies available to staff at the facility. Observations indicated that each of the three supply closets had a large stock of hygiene supplies in different sizes available. There were also hygiene supplies in resident rooms available for staff and resident use. Interviews with Staff members S1, S2, S3 and S4 indicated that there is a good supply of hygiene products that are available for use for resident care. Therefore, the allegation lack of hygiene supplies in unfounded. Lack of appropriate incontinence care leading to wounds Records reviewed indicated that there are no residents who currently have open wounds at the facility. Staff are doing checks for wounds during brief changes and showering. Staff document if there are any skin integrity issues while showering. Interviews conducted with Staff members S1, S2, S3 and S4 indicated that there are no current residents with wounds at this time. Staff check residents daily to ensure there are no new skin issues, this is done during brief changes and showering. Therefore, the allegation lack of appropriate incontinence care leading to wounds is unfounded. Kitchen area not kept sanitary Observations indicated that kitchen is kept clean, sanitary and free of any pests. Records reviewed indicated that facility kitchen is audited once a quarter in order to check for cleanliness and overall sanitation along with food management. In review of the audit reports, it was indicated that the facility has maintained a 100% score in sanitation and overall kitchen services with no areas of concern. Interviews conducted indicated that kitchen is maintained as a clean environment with proper procedures in place to uphold kitchen and food standards. Therefore, the allegation kitchen area not kept sanitary is unfounded. Staff are not following activity schedule Interviews conducted indicated that the facility utilizes a program called “The Moment Program” which allows the facility to pivot their activities schedule based on the residents abilities. The program is flexible and supports individualized care and resident choices. Observations indicated that staff were assisting residents with activities, residents were also participating in watching a movie, and staff were heard asking residents what activity they would like to participate in at that time. Therefore, the allegation staff are not following activity schedule is unfounded. Continued on 9099-C2 page Incidents are not being reported by appropriate agencies Records reviewed indicated that facility is reporting to appropriate agencies in a timely manner. Review of facility procedures indicated that staff are trained on how and when to report to the appropriate agencies. Interviews conducted indicated that when an incident occurs, it is documented and the proper staff are notified, then the appropriate agencies are notified either via phone call or LIC624 incident report sent by email or fax. Therefore, the allegation incidents are not being reported by appropriate agencies in unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.