complaint·April 7, 2026

Sharp objects are not locked and inaccessible Interviews conducted with Executive Director and Staff members S1 and S2 indicated there have been no incidents related to sharp objects to their knowledge. Facility tour indicated that all drawers accessible to residents in care did not have any sharp objects available for resident use or access. All sharps were locked and inaccessible to residents in care. Records reviewed indicated that there have been no reports from the facility of sharps being left unlocked or incidents where a resident has gotten a hold of a sharp object due to lack of supervision. Therefore, the allegation sharp objects are not locked and inaccessible is unsubstantiated. Not enough staff to meet resident's needs Interviews conducted with Executive Director and Staff Members S1 and S2 indicated that staffing is improving. Staff are able to complete assigned work and the facility is no longer using an outside agency to fill in staff. 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 to assist with level of acuity in the current residents. Resident records reviewed indicated that staffing is appropriate for the residents level of care. 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 Executive Director. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.