Complaint·July 17, 2025

On 7/17/25 LPA Hughes conducted a follow-up facility visit and observed the facility refrigerator 2-day perishables food supply. Two-day perishables in the facility refrigerator were observed pre-made with dates on the containers; food was observed appropriate for residents with specific dietary needs. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time. Allegation: Staff spoke inappropriately to resident It was alleged that staff spoke inappropriately to resident. This investigation consisted of interviews with witnesses, facility staff and residents. On 4/29/2025, during a visit to the facility witness (1) stated that they observed an interaction between facility administrator and resident (R2) stating that facility administrator spoke inappropriately to resident (R2). Additionally, interview with R2’s private caregiver reflected that there were no concerns of staff speaking inappropriately to residents in care. Interview with 1 facility staff indicated that, staff have not spoken to residents inappropriately and have not witnessed other staff speak to residents inappropriately. Interview with resident (R2) reflected no concern with facility staff speaking inappropriately themselves or other residents in care. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time. Staff not accommodating residents needs It was alleged that staff are not accommodating residents needs. This investigation consisted of interviews with facility staff and residents. On 7/1/2025 LPA Hughes conducted a follow-up visit to the facility. Interview with residents in care reflected that 3 out of 5 residents in care have no concern with staff not accommodating the needs of residents in care. On 7/17/2025 LPA Hughes conducted a follow-up visit and observed facility staff assisting residents with seating for lunch. Based on the information obtained, there is no evidence to support the allegation, therefore it 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. Resident (R2) had (1) medication that was signed off as administered but the medication could not be located in the facility, R2’s Centrally Stored Medication Destruction Record (CSMDR) could not be located in the resident’s medication log. Resident (R3) had inconsistencies in the start date and amount of medication on hand. Interview with facility staff revealed that there were known discrepancies in medication administration, which had not been addressed or corrected at the time of the facility observation. This allegation was observed not in compliance with Title 22 regulations 87465(a)(6) Incidental Medical and Dental Care. The facility did not ensure that an accurate record of residents medication was maintained at the facility. As a result, this allegation is SUBSTANTIATED . A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Lita Siebenthal and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.