Complaint·December 10, 2025

Residents stated that the food being served is of good quality and meets their needs. LPA attempted to interview resident (R1) but was unable as they no longer live in the facility. Interview with 1 facility staff (S1) stated that the facility has implemented weekly menus to assist facility staff and residents maintain healthy diets that meet their nutritional and dietary requirements of the residents in care. Due to insufficient evidence, this allegation could not be corroborated therefore the allegation is unsubstantiated. Allegation: Staff allow residents to be left in soiled clothing for extend periods of time It was alleged that staff allow residents to be left in soiled clothing for extended periods of time. This investigation consisted of interviews with facility staff, residents, and facility observations. On 10/14/2025 LPA Hughes conducted a visit to the facility. LPA spoke with 1 facility staff who stated that they have not received any concerns about incontinent care in the facility. Facility staff (S1) stated that 4 out of 6 residents require assistance with showering needs in the facility. Interview conducted with 4 out of 5 residents reflected no reported concerns with facility staff meeting their sanitary and hygiene needs. LPA attempted to interview resident (R1) but was unable as they declined interview with LPA. On 12/10/2025 LPA Hughes conducted a follow-up visit to the facility, during facility observation residents in care appeared clean, groomed, without any noticeable odors. This allegation could not be corroborated due to insufficient evidence, therefore the allegation is unsubstantiated. Allegation: Staff are financially abusing residents in care It was alleged that staff are financially abusing residents in care. This investigation consisted of facility observations, interviews with facility staff and residents, and records review. On 10/14/2025 LPA conducted a visit to the facility, and spoke with 1 facility staff (S1) who stated that the facility does not hold or supervise residents cash resources, S1 further stated that any concerns regarding residents’ property and money missing are addressed and recorded by the facility. Interview with 2 out of 5 residents in care indicated that they have no concerns about facility staff financially abusing them, and that they are aware of the facilities policy of holding no liability for missing money in the facility. LPA attempted to interview 2 additional residents (R1) and (R4) but was unable as both resident declined interview. A review of the facility Admission Agreement indicated that the facility holds no liability for money kept in the facility, the agreement was acknowledged and accepted upon by residents in care. There is no evidence to support this allegation, therefore the allegation is unsubstantiated. Continuation 9099-C Allegation: Staff does not ensure residents personal property is safely secured It was alleged that staff do not ensure residents personal property is safely secured. This investigation consisted of interviews with residents and facility staff, and records review. On 12/10/2025 LPA Hughes conducted a visit to the facility and spoke with 4 out of 5 residents, who all stated they have no concerns with their personal property not being safe in the facility. Interview with 1 facility staff (S1) stated that residents have not raised concerns regarding their personal property not being safe in the facility. S1 stated that all concerns regarding residents personal property being lost or stolen are promptly addressed and documented by facility staff. LPA observed that facility staff utilize the LIC 9060 Resident Theft and Loss Record to track and document residents missing or lost items. Additional review of resident records indicate that resident R1's LIC 621 Client/Resident Personal Property and Valuables indicate that resident (R1) admitted to the facility with (1) mobile device and (1) clothing item entrusted to the facility. Due to insufficient evidence, this allegation could not be corroborated therefore the allegation is unsubstantiated. Allegation: Staff do not prevent resident from entering other residents rooms It was alleged that staff do not prevent residents from entering other residents rooms. This investigation consisted of interview with facility staff and residents, and facility observations. On 10/14/2025 LPA Hughes conducted a visit to the facility, during the visit LPA spoke with 2 out of 5 residents who stated that they have no concerns about residents entering their rooms unannounced. Additional interview with facility staff (S1) reflected that residents are encouraged to socialize with other residents if they are welcome, S1 stated that whenever a resident does enter a resident’s room unannounced they are redirected to leave the residents room. On 12/10/2025 LPA Hughes conducted a follow-up visit to the facility and interviewed 4 of out 5 residents. Of those interviewed, 3 residents reported no concerns with staff not preventing other residents from entering their rooms. LPA attempted to interview resident (R4) but was unable as they declined to be interviewed at this time. Facility observation reflected that all residents were in their own rooms, LPA observed resident (R4) on multiple occasions outside of their own room in the common area watching television. Due to insufficient evidence, this allegation could not be corroborated at this time. 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 violations occurred.