complaint·November 17, 2025

Continued from LIC9099 2 of 4 Staff interviews confirmed that the resident receives assistance with activities of daily living (ADLs), medication management, and intermittent home health services, all of which are allowable under RCFE regulations. Executive Director stated that the resident’s condition is regularly assessed and that any changes in condition are communicated to the physician and the responsible party. Additionally, there was no evidence that the resident had been denied access to appropriate medical care or that the facility failed to coordinate with outside providers when needed. Observations during the visit showed the resident was alert, oriented, and participating in daily activities. There were no signs of neglect or unmet medical needs. The facility demonstrated compliance with Health and Safety regulations, which prohibits retention of residents who require care beyond the facility’s capabilities unless appropriate waivers or support services are in place. On 2/26/25, it was alleged that the staff does not ensure that residents' confidential information is safeguarded. During the investigation, staff interviews confirmed that all employees receive training on confidentiality and resident rights upon hire and annually thereafter. Staff demonstrated knowledge of procedures for handling and storing resident records in compliance with regulations which requires that resident records be kept confidential and stored in a manner that ensures privacy. Observations during the facility visit confirmed that resident files are stored in a locked cabinet in a secure office area accessible only to authorized personnel. No records were observed left unattended or in public view. Medication Administration Records (MARs), physician orders, and care plans were reviewed and found to be properly maintained and secured. Staff were observed logging out of electronic systems when not in use, and no breaches of confidentiality were identified during the visit. Additionally, there were no complaints or incident reports on file indicating that any resident’s personal or medical information had been disclosed inappropriately. The facility’s practices are consistent with Health and Safety regulations, which requires that facilities protect the confidentiality of resident records and only release information to authorized individuals. (Continued from LIC9099C 3 of 4) On 2/26/25, it was alleged that the staff are administering medications to residents that are not authorized. Based on the investigation conducted, which included interviews with facility staff, residents, and outside sources such as responsible parties and the residents’ physicians, there is insufficient evidence to support the allegation that facility staff are administering medications to residents without proper authorization. A thorough review of centrally stored medication records, physician orders, and Medication Administration Records (MARs) revealed that all medications administered were prescribed by a licensed physician and documented in the residents’ files. Staff interviews confirmed that only trained and authorized personnel are responsible for medication administration, and staff demonstrated knowledge of proper procedures during observed medication passes. Outside sources, including physicians and responsible parties, verified that all the medications were authorized and consistent with the residents’ care plans. No inconsistencies were found between physician orders and the medications administered. On 2/26/25, it was alleged that the staff do not safeguard residents' personal possessions. Based on the investigation, which included interviews with facility staff, residents, and responsible parties, as well as a review of facility policies, incident reports, and personal property records, there is no evidence to support the allegation that facility staff are not safeguarding residents’ personal possessions. Residents and responsible parties interviewed did not express concerns about missing or mishandled belongings, and several confirmed that their items were secure and accounted for. Staff interviews indicated that the facility has procedures in place for documenting and protecting residents’ personal property, including the use of inventory forms and secure storage when needed. A review of these records showed that personal items were properly logged and no recent complaints or theft reports were found. Observations during the visit confirmed that residents’ rooms were orderly and that personal belongings appeared to be respected and maintained. On 2/26/25, it was alleged that the staff do not ensure that the resident's representative has prompt access to review the resident's records. Outside sources were interviewed and they confirmed they were able to access records upon request. Staff were interviewed and they were aware of the regulations that pertain to resident's representative access to records. (Continued from LIC9099C 4 of 4) This agency has investigated the complaint alleging that the licensee failed to protect the resident from harm and the licensee failed to facilitate medical care for the resident. The Department has found 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; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report and licensee rights (LIC 9058 03/22) was provided.  Executive Director Natalie Carlborg's signature on this form confirms receipt of these rights.