complaint·August 21, 2025

(Continued from Page 1) On the allegation: Staff are chemically restraining residents in care. It was alleged staff are giving THC drinks to keep residents sedated. LPA did not observe any drinks labeled with THC in the pantry, other cabinets, drawers inside the kitchen, did not observed any prescribed medications for clients for THC. Interviews were conducted with Staff and witness did not corroborate that residents are given THC. Medication lists for Resident #1 (R1) and Resident #2 (R2) were reviewed by LPA revealed residents have a doctor’s order for Nutrilite sleep Health which is a supplement were prescribed for R1 and R2, it is not THC. On the allegation: Staff are physically restraining residents in care. It was alleged staff are placing weighted vests on residents to keep them immobile, at bedtime to keep them in bed and side rails are attached to aide in restraining. LPA conducted a tour of the resident bedrooms and common areas and observe a resident wearing a light blue color terry cloth bib that is attached by a snap button laying in bed watching TV eating food. The bib did not weigh 20 pounds, is made from fabric and is used by residents that may need assistance in keep their clothes clean, a half side rail was observed in one resident room that was attached to the bed and it was half a rail not a full rail, LPA did observe a doctor order for rails to be used for resident. LPA did not observe any weighted vests and rails stored inside resident’s closets, garage or laundry areas. Interviews were conducted with Staff and witness did not corroborate that staff are physically restraining residents. On the allegation: Food Service are inadequate; it is alleged that staff give residents protein drinks without doctors’ orders. LPA reviewed food supply in the kitchen areas and there is enough food supply and there are different options that residents are prepared to eat. LPA observed snacks given to residents at the dining table during the afternoon on a visit at the facility. LPA observed Nurtrilite organics all-in-one shakes and a bag plant protein powder inside the pantry. LPA observed doctor’s orders for the protein drinks for (R1) and (R2). Interviews were conducted with Staff and witness did not corroborate that food service is inadequate, and residents are being given protein drinks without doctor’s orders. Based on records review, staff interviews and witness’s 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 with Elizabeth Hengstler and a copy of this report was provided.