Complaint·July 11, 2025

Second allegation, staff do not have fingerprint clearance. LPA retrieved a facility roster via Guardian Background System and observed that Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3) that are currently working at the facility were eligibly cleared. LPA conducted a file review for Staff 1-3 and discovered that all clearance records were on file. Third allegation, staff lock facility doors to prevent residents from leaving. LPA conducted a walk through of the facility and inspected resident's bedrooms and doorknobs. LPA observed that no latches and/or child proof locks were in place. LPA conducted an inspection on all doors and emergency exits and observed that no latches and/or child proof locks were in place. Two (2) residents interviewed deny being locked or prevented from leaving the facility. Two (2) other residents interviewed were unable to answer due to cognitive impairment. Three (3) staff interviewed denied locking and/or preventing residents from leaving the facility. Fourth allegation, staff insert suppositories to residents in care. Three (3) staff interviewed denied utilizing or inserting suppositories to residents. Two (2) residents interviewed denied staff inserting suppositories for the residents. Two (2) other residents interviewed were unable to answer due to cognitive impairment. Staff #2 (S2) mentioned that Resident #1 (R1) does use suppository. The nurse from Brookside Hospice comes to the facility to assist R1 with the suppository. Fifth allegation, staff did not complete required trainings. LPA conducted staff file reviews and observed that training was completed. LPA observed certificates of completion to be on file for staff. Sixth allegation, staff facility records are falsified. LPA conducted a First Aid & CPR verification through National CPR Foundation and New Life CPR, these agencies are used by the facility to certify staff. Staff 1-3 are certified for First Aid & CPR certification. Seventh allegation, staff did not maintain resident records. LPA conducted a file review for three (3) residents and observed that all required documentation were on file based on Title 22 Residential Care Facility for Elderly (RCFE). Eight allegation, residents are not provided proper food service. LPA conducted an inspection on facilities food supply and observed that the facility has adequate amount of food supply to meet resident needs. LPA observed that all food including canned goods sustained current shelf life. Two (2) residents interviewed stated that the food is good and has no concerns. Two (2) other residents interviewed were unable to answer due to cognitive impairment. Ninth allegation, staff did not ensure resident’s diapering needs were met. Three (3) staff interviewed stated that they do ensure that resident's diapering needs are being met. Resident #2 (R2) stated that they do not use diapers. Resident #3 (R3) stated that staff does ensure that their diapering needs are met. Two (2) other residents interviewed were unable to answer due to cognitive impairment. Based on LPA observations, residents diapering needs are being met, the residents are kept clean and free of odors. Based on evidence obtained during this investigation, the allegations above are Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy of this report was provided to Iren Creighton at the conclusion of the visit. Staff #1 (S1) and Staff #2 (S2) stated that they do provide adequate medication assistance to residents. LPA conducted file reviews of residents Medication Administration Record (MAR) and observed that all medication is being distributed and managed correctly by staff. The allegation that staff refuse to call an ambulance for residents in care. Two (2) residents interviewed stated that staff has not refused to call ambulance for residents. Two (2) other residents interviewed were unable to answer due to cognitive impairment. Three (3) staff interviewed stated denied refusing to call an ambulance for residents in care. The allegation that staff threatened residents in care. Two (2) residents interviewed stated that staff has not threatened residents .Two (2) other residents interviewed were unable to answer due to cognitive impairment. Three (3) staff interviewed stated denied threatening residents in care. The allegation that staff did not ensure sufficient food items were available at the facility for residents in care. LPA conducted an inspection on facility's food supply and observed that there is an adequate amount of food supply to meet resident needs. Two (2) residents interviewed stated that the food provided is fulfilling and have no issues with the food. Two (2) other residents interviewed were unable to answer due to cognitive impairment. The allegation that staff did not prevent residents from engaging in inappropriate interactions. Two (2) residents interviewed stated that they have not engaged in inappropriate interactions and have not witnessed inappropriate interactions at the facility. Two (2) other residents interviewed were unable to answer due to cognitive impairment. Three (3) staff interviewed stated that they do prevent residents from engaging in inappropriate interactions. The allegation that staff yelled at residents in care. Two (2) residents interviewed stated that staff has not yell at residents in care or witnessed it at the facility. Two (2) other residents interviewed were unable to answer due to cognitive impairment. Three (3) staff interviewed stated deny yelling at residents in care and have not witnessed a staff yelling at a resident in care. The allegation that staff did not assist residents that sustained falls. Two (2) residents interviewed stated that staff does assist residents with transfers and are very involved and deny witnessing residents sustain falls and not being assisted by staff. Two (2) other residents interviewed were unable to answer due to cognitive impairment. Three (3) staff interviewed stated that they do assist residents in care. The allegation that centrally stored medications are accessible to residents in care. LPA conducted a walk through of the facility and observed that the medications are locked and secured in the kitchen cabinets. During the inspection, staff opened the cabinets with a magnet and demonstrated that medication cabinets remain locked and inaccessible to residents in care. Based on evidence obtained during this investigation, the allegations above are Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy of this report was provided to Iren Creighton at the conclusion of the visit. The allegation that staff are not following reporting requirements. LPA conducted interviews with staff who informed LPA that Special Incident Reports (SIR) are faxed to Community Care Licensing Division (CCLD) when pertaining to any incident involving residents in care. The allegation that staff left residents unattended. Two (2) residents interviewed denied being left alone and/or unattended at the facility. Two (2) other residents interviewed were unable to answer due to cognitive impairment. Three (3) staff interviewed denied leaving residents unattended or unsupervised. Based on evidence obtained during this investigation, the allegations above are Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy of this report was provided to Iren Creighton at the conclusion of the visit