complaint·March 30, 2026

The facility allowed excluded individuals to work in the facility. Documents reviewed indicated that all staff present at the facility and currently listed on the staff roster are fingerprint cleared and associated to the facility. Interviews conducted with Administrator indicated that there are no uncleared staff at the facility and Administrator explained how she conducts hiring and fingerprinting staff prior to start date at the facility. Therefore, the allegation the facility allowed excluded individuals to work in the facility is unfounded. Staff are forging resident documents. Documents reviewed indicated that all physician signatures were from separate physicians and matched other signatures in each resident specific files. All resident files included all documents to meet regulatory requirements. In review of the staff files, signatures and printed names matched each staff file. Therefore, the allegation staff are forging resident documents is unfounded. The Administrator is not present at the facility for a sufficient amount of time. Observations made on unannounced visits by the Department made on 10/14/2025, 11/6/2025 and 2/19/2026 which indicated that the facility’s administrator was present at the facility. Documents reviewed indicated that a current staff schedule is being followed and is accurate to current staff working. Therefore, the allegation the administrator is not present at the facility for a sufficient amount of time is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.