complaint·September 15, 2025

It was also alleged that the facility is understaffed. During today's visit Staff 1 (S1) was the only staff present to provide all care and meals for five (5) residents, at the time of LPA's arrival. An interview with S1 revealed their main role was working as kitchen staff, however, was capable of providing care for the residents. S1 also disclosed their shift (today) began at 7:00 am. and ends at 6:00 pm., Staff 2 (S2) starts their shift at 8:00 am., who is trained to assist with insulin, however due to car issues did not arrive until 11:30 am., S1 revealed Resident 1 (R1) usually wakes up between 8:30 am. and 9:00 am., upon waking up R1 typically will have assistance to test their blood sugar level to determine if administration of insulin is needed, prior to breakfast. Today, due to S1 not being trained to assist R1 did not receive their testing/injection. Based on Staff interviews, and record reviews, the complaint allegations were determined to be SUBSTANTIATED. A substantiated finding means the preponderance of evidence was met to prove the above listed allegations were met. An exit interview was conducted with Staff Magat and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of the visit. Staff interviews and resident records reviews revealed staff notified R1's hospice agency of the issue and subsequently the hospice agency staff removed R1's catheter. Based on interviews and record reviews the above listed allegation was determined Unsubstantiated. This finding means the preponderance of evidence standard was not met. An exit interview was conducted with Staff Magat and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of the visit.