complaint·February 12, 2026

THIS IS AN AMENDED VERSION OF THE ORIGINAL REPORT TO REMOVE ALLEGATION #3. LPA Lee also interviewed three facility staff, all of whom denied the allegation and stated that Resident 1 (R1) had a physician’s order authorizing the use of a blanket and a wheelchair safety belt for R1’s safety. An interview with an outside agency indicated that they had not observed any residents being restrained. Additionally, an interview with R1’s responsible party revealed no concerns regarding the allegations, abuse, or neglect by facility staff. A review of records showed that R1 was placed on hospice care and that a physician’s order was in place authorizing the use of a floating blanket system for bed safety and a wheelchair safety belt to provide protective postural support. Based on the interviews conducted and the records reviewed during the investigation, LPA Lee was unable to corroborate the allegation. It was alleged that staff were chemically restraining residents in care. This investigation consisted of interviews with staff, residents, and an outside agency, as well as a review of records. LPA Lee interviewed three of three residents, all of whom stated they had no concerns regarding their medications and reported that medications are administered by facility staff. LPA Lee also interviewed three facility staff members, all of whom denied the allegation and stated that medications are administered in accordance with physicians’ orders and that no residents are chemically restrained. An interview with an outside agency indicated no concerns regarding residents’ medications. A review of medications was conducted for five out of five residents by examining the medications stored in each resident’s medication box. The review indicated that all medications present were prescribed by a physician. During records review, it was learned that the facility was not consistently or accurately documenting medication administration on residents’ Medication Administration Records (MARs). Additionally, the facility was not properly maintaining centrally stored medication destruction records; however, no evidence was identified to indicate that medications were administered for the purpose of chemical restraint. It was also learned that Resident 1 (R1)’s medications were removed from the facility by hospice following R1’s death and were therefore unavailable for review. Based on R1’s MAR records it indicated that R1 was receiving R1 medication as it was initialed given for the month of June 2025 to November 2025. Based on the interviews conducted and a review of available records, there was insufficient evidence to support the allegation that staff are chemically restraining residents in care. CONTINUED LIC 9099-C THIS IS AN AMENDED VERSION OF THE ORIGINAL REPORT TO REMOVE ALLEGATION #3. It was alleged that staff were not meeting residents’ toileting needs while in care. This investigation included interviews with staff, residents, and an outside agency, as well as direct observations. LPA Lee interviewed all three residents, each of whom reported no concerns regarding their incontinence care and confirmed that staff assist them as needed. Interviews with three facility staff members denied not assisting residents with toileting needs. An outside agency also reported no concerns and stated that they had not observed any incontinence odors at the facility. During a facility visit on January 30, 2026, LPA Lee did not detect any incontinence odors and observed a staff member assisting Resident 2 (R2) with incontinence care. Additionally, a whiteboard located at the entry wall was observed displaying residents’ names, responsible party contact information, doctor’s appointments, and the date of each resident’s last bowel movement. Based on the interviews and observations conducted during this investigation, LPA Lee was unable to corroborate the allegation. It was alleged that staff were not preventing residents’ beds from being infested by bedbugs. This investigation included interviews with staff, residents, and an outside agency, as well as observations and records review. LPA Lee interviewed three facility staff, all of whom reported that they had not observed bedbugs on residents’ beds and confirmed that the facility uses pest control services. Interviews with all three residents also indicated that they had not seen bedbugs on their beds and had no concerns regarding the allegation. Additionally, an outside agency reported no observations of bedbugs in residents’ rooms or on their beds. During a facility visit on January 30, 2026, LPA Lee toured the facility with care staff Dagohoy and inspected six resident bedrooms, including beds, sheets, and mattresses. No pests were observed. CONTINUED LIC 9099-C Records review confirmed that the facility does have pest control services. Based on the interviews, observations, and records review, LPA Lee was unable to corroborate the allegation. It was alleged that staff were not properly addressing a resident’s wounds . During this investigation, it was determined that Resident 1 (R1) had been placed on hospice and was diagnosed with a underlying health condition that causes involuntary, spasm-like movements. These movements often resulted in R1 thrashing, which caused self-inflicted injuries to the arms, legs, and head, including impacts against the bed, wheelchair, or other surfaces such as a sofa. All staff interviewed denied not addressing R1’s wounds, stating that the wounds were being regularly cleaned and dressed by the hospice nurse and that these interventions were documented in R1’s hospice notes. Records review confirmed that R1’s wounds were being addressed by the hospice nurse and that all care was documented in R1’s file. Additionally, hospital staff reported no concerns of abuse and documented that R1’s injuries were consistent with their underlying medical condition. Based on the review records, the allegation could not be corroborated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.