complaint·January 8, 2026

As to the allegation of, “Staff does not ensure facility in maintained in good repair.” It was alleged that R1’s room was in disrepair, with unsafe wiring hanging out of the walls. On 10/28/2025 LPA conducted a phone interview with Reporting Party, who stated that the room is unsafe because there are wires coming out of the walls everywhere in that room. On 10/30/2025, LPA Jeffries conducted a physical tour of the facility and R1’s bedroom and observed nine (9) individual charging cables connected to a charging hub on R1’s dresser, the cables were hanging off the dresser. LPA noted no wires or unsafe issues on the walls or in the room in its entirety. On 10/30/2025 LPA Jeffries conducted an interview with R1 who stated that all the charging cables are (R1’s) charging cables and needs them placed the way that they are so (R1) can manage to charge (R1’s) cell phone and other devices. On 10/30/2025 LPA Jeffries conducted an in-person interview with Staff 1 (S1). S1 stated that R1 tells staff not to touch R1’s belongings. S1 stated that they have attempted to clean R1’s room and R1 refuses to allow staff to touch anything in R1’s room. On 10/30/2025, LPA Jeffries conducted an in-person interview with facility Administrator, Susan Marsh, who stated that, “R1 yells at us (Staff) when they asked to clean up in R1’s rooms. Administrator stated that R1 has trust issues. Based on complaint narrative and intake interview, LPA observations, and interviews, there is not enough evidence to support the allegation of, “Staff does not ensure facility in maintained in good repair.” and is unsubstantiated at this time. As to the allegations of, “Staff does not follow dietary plan for resident in care.” and “Staff does not ensure food portions are of adequate serving sizes.” It was alleged that R1 is a vegetarian and the administrator is not following R1’s dietary plan which has resulted in R1 losing a lot of weight over the last few months. On 10/30/2025 LPA Jeffries conducted an interview with R1 who stated, “I don’t like the food she (Administrator) buys so I buy my own.” “She (Administrator) will buy vegetarian items, but I like certain things that I buy myself.” On 10/30/2025, LPA Jeffries conducted an in-person interview with S1, S1 stated that they offer R1 a vegetarian diet. LPA observed S1 cutting vegetables and making vegetarian stew/soup. On 10/20/2025 LPA Jeffries conducted an in-person interview with Administrator who stated that the facility provided a vegetarian menu for R1 and provided examples items from the pantry and refrigerator. Administrator stated that R1 likes to buy specialty food items. Administrator stated that the serving portions are up to the residents and how much they want. On 10/30/2025, LPA conducted an in-person interview with Resident 2 (R2) R2 stated that they have no issues with food or portion sizes at this facility. On 10/30/2025, LPA Jeffries observed fruits, vegetables, and other frozen vegetarian labeled foods on hand at the facility. Based on interviews, and observations there is not enough evidence to support the allegations of, “Staff does not follow dietary plan for resident in care.” and “Staff does not ensure food portions are of adequate serving sizes.” and both are unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegations of, “Staff does not ensure residents transportation needs are being met.” and “Staff does not ensure residents health care needs are being met.” It was alleged that the administrator will not provide assistance in arranging transportation for R1’s doctor’s appointments. On 10/30/2025, LPA Jeffries conducted an in-person interview with R1, who stated that, “I haven’t missed any doctors’ appointments, I have a friend who takes me when and where I need to go.” R1 also stated, “I would rather have my friend take me to my doctors’ appointments. I suppose (Administrator) could take me, but I don’t need her because I have my own ride.” On 10/30/2025 LPA Jeffries conducted an in-person interview with Administrator who stated that R1 has a Friend from the community (F1) take R1 out in the community most days. Administrator stated that she has taken R1 to appointments before and the facility will take residents to their appointments as they are needed. On 12/04/2025, LPA observed F1 pick up R1 for a community outing. Based on interviews, admission, and observations, there is not enough evidence at this time to support the allegations of, “Staff does not ensure residents transportation needs are being met.” and “Staff does not ensure residents health care needs are being met.” and is unsubstantiated at this time. As to the allegation of, “Staff does not ensure medications are dispensed as prescribed.” It was alleged that R1 gets nose bleeds and administrator will not provide any assistance with medication to help stop the nose bleeds and the administrator won't dispense the medication. On 10/30/2025 LPA Jeffries conducted an in-person interview with R1 who stated, “I don’t have any problems with taking any of my medications, I just didn’t get it the other night.” On 10/30/2025 LPA Jeffries conducted a medication audit of R1’s medication, centrally stored medication record and medication administration record. LPA noted that medications are noted as being dispensed as prescribed and medication count is correct on 10/20/2025. LPA conducted an interview with S1 who stated that, a few days ago (unsure of what day, about 3 days estimate) R1 had requested help with a nosebleed during the early morning. S1 was assisting another resident and it took approximately 10 to 15 minutes after R1 had requested the medication in question. On 12/04/2025 LPA Jeffries conducted an additional medication audit and found no issues with medication administration, centrally stored medication records and pill count, with no issues. Based on interviews, admission, medication audit and documentation there is not enough evidence at this time to support the allegation of, “Staff does not ensure medications are dispensed as prescribed.” and is unsubstantiated at this time. Exit interview, report read, and report provided.