complaint·March 19, 2026

Allegation: staff administering medication without resident’s knowledge or consent LPA learned that R1 has a crush order for one medication. LPA reviewed medications for R1. R1 has an order for Depakote Sprinkles which states: sprinkle contents of 1 capsule on food and eat 3 times a day. Additionally, R1 has a crush order for Trazadone which is mixed with chocolate syrup, applesauce, or pudding and given in a kitchen spoon. Allegation: Staff not properly preparing resident medication According to the complaint filed, staff were prepouring medication. LPA reviewed the mediation cabinet and did not find any evidence that medications were prepoured. There were no medication cups or medication pill organizers for staff to use in order to prepour medications. Additionally, no staff interviews acknowledged that medications were being prepoured. Allegation: Staff are not following food sanitation practices when preparing food for residents LPA toured the kitchen and inspected the kitchen cabinets. LPA did not find any evidence of the kitchen being unsanitary. All staff interviewed stated that the kitchen is kept clean at all times. Allegation: staff leave residents attended LPA observed 3 staff to be at the facility upon arrival for the complaint visit. LPA reviewed the facility’s LIC500 which showed staff at the facility at all times. Additionally, per staff interviews and the LIC500, there is awake staff for the overnight shift. No staff interviews acknowledged that residents were being left unattended. Allegation: Staff do not inform residents’ responsible parties of incidents LPA reviewed phone calls logs and text messages between POAs and the Administrator. Call logs and text messages showed constant communication between the facility and responsible parties. Staff interviews stated that there have not been any concerns from families about not being informed. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was provided to the facility.