complaint·May 21, 2025

It was alleged staff are providing THC drinks/protein powder to residents without a physician’s order. LPA toured interior and exterior of the facility. LPA did not observe any THC drinks in the facility. LPA observed supplementary drinks with protein in the pantry. 3 out 5 residents consume the protein drinks. LPA observed doctor’s orders for the protein drinks in those three (3) residents files. It was alleged staff are restricting visiting hours. LPA observed the facility visiting policy outlining visiting hours next to the front door. Staff members confirmed visitors who come after hours will be allowed entry after calling the licensee. Staff members stated they have never turned away any visitors. It was alleged residents are charged for services not rendered. LPA’s interview with the administrator revealed the only extra charge to the resident’s account will be the incontinence supplies. LPA’s review of the admission agreement revealed each resident receives basic care services and their charges are aligned with the basic level services. It was alleged residents moved to other facilities without consent. LPA’s interview with the administrator revealed residents sometimes visit another facility owned by the same licensee when there are community activities. LPA observed three (3) residents receiving haircuts, and one of the residents returned to their home facility after their haircut. It was alleged residents are left unattended. LPA’s interview with two (2) staff members revealed the facility has live-in caregiver (S1). LPA reviewed the staff schedule and S1’s live-in employment agreement. LPA did not observe any gaps in the staff schedule. Both staff members denied ever leaving the residents in care unattended. It was alleged staff put up bed rails without physician’s orders. LPA observed 1 of 5 residents with full bed rails. LPA observed 3 of 5 residents have half bed rails. LPA’s file review revealed resident #1 has doctor’s order for full bed rails, and residents #2, #3, and #4 also have doctor’s orders for half bed rails. Based on records review, resident interviews, and staff interviews, above allegations are Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.