complaint·November 20, 2025

On June 20, 2024, LPA Simi Rai interviewed staff S1. S1 stated he/she does not recall if a resident consumed medications that were left on the table. S1 stated in Memory Care unit the protocol is to ensure the resident takes the medication and wait with them until they swallow the medication. S1 stated the med-tech doesn’t leave the medication lying around because the resident may forget to take the medication. On September 30, 2025, LPA Manuel Monter interviewed residents R3-R7. 5 Out of 5 residents (R3-R7) stated they handle their own medications, doesn’t need staff assistance and hasn’t had any issues with his/her medications. LPA Monter interviewed Staff S1-S3, S5. LPA also interviewed S4 & Current Memory Care Director, Norlynn Peterson. Staff S1-S3 & S5 stated staff gives residents their medications in person. Staff S1-S3,S5 stated medications are not given when residents are dinning. 5 Out of 5 staff (S1-S5) stated they haven’t seen or heard about residents taking each others medications. On October 6, 2025, LPA Manuel Monter interviewed Witness W1. W1 stated he/she doesn’t remember when the incident where R1 took R2’s medication occurred. W1 stated he/she was contacted by an unknown staff who informed him/her about this incident. On November 20, 2025, LPA Monter interviewed residents R2, R8-R11. 2 Out of 5 residents(R8, R9) interviewed stated they have not had any issues with receiving their medication. 2 Out of 5 residents(R8, R9) interviewed stated there hasn't been a time when they observed a resident taking other residents medication. 3 Out of 5 residents (R2, R10, R11) interviewed were unable to provide any relevant information due to neruocgonetive disorder. LPA interviewed staff S6-S9. 4 Out of 4 staff (S6-S9) stated medications are administered to residents in person, and the medtech will watch them take the medication before leaving. 4 Out of 4 staff (S6-S9) stated they haven't seen or heard about any instance of a resident taking another residents medication and consuming it. Page 2 Out of 5 On November 20, 2025, LPA Manuel Monter randomly audited 5 resident’s medications. LPA audited the medications by cross referencing the medication bottles/ containers and cross referencing with the Centrally Stored Medication Record and Medication Administration Record. No discrepancies were noted during review. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff did not prevent resident from wandering into another resident's room On June 13, 2024 the Department received a complaint alleging Staff did not prevent resident from wandering into another resident's room. On June 13, 2024, the Department interviewed Witness W1. W1 stated that in January 2023 (W1 doesn't know the date of this event) during dinner time, staff went looking for R1 and found the R1 lying on the floor in another resident's room. W1 stated he/she doesn't know how long R1 was inside of the other resident's room. On June 20, 2024, LPA Simi Rai interviewed Staff S1. S1 stated he/she does not recall when R1 was found lying on the floor of another resident's room. On September 30, 2025, LPA Manuel Monter interviewed residents R3-R7. 5 Out of 5 residents (R3-R7) stated they have not had any issues with other residents wandering into his/her apartment. LPA Monter interviewed Staff S1-S3, S5. LPA also interviewed S4 & Current Memory Care Director, Norlynn Peterson. 5 Out of 5 staff (S1-S5) interviewed stated if there residents who attempts to enter another resident’s bedroom, then staff will redirect them. On October 6, 2025, LPA Manuel Monter interviewed Witness W1. W1 stated regarding R1’s wandering, that he/she was informed by an unknown staff. W1 stated he/she doesn’t remember what room R1 entered or how long R1 was there. Page 3 Out of 5. On November 20, 2025, LPA Monter interviewed residents R2, R8-R11. 2 Out of 5 residents(R8, R9) interviewed stated they have not had any issues with other residents wandering or going into their bedroom and have not witnessed that occurring. 3 Out of 5 residents (R2, R10, R11) interviewed were unable to provide any relevant information due to neruocgonetive disorder. LPA interviewed staff S6-S9. 4 Out of 4 staff (S6-S9) stated there are residents who have the behavior of wandering and attempting to enter another residents bedroom. 4 Out of 4 staff (S6-S9) stated when this behavior is observed, staff will re-direct the resident. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff did not notify responsible party regarding increase of facility fees On June 13, 2024 the Department received a complaint alleging Staff did not notify responsible party regarding increase of facility fees. On June 13, 2024, the Department interviewed Witness W1. W1 stated in January 2024 (W1 stated he/she doesn't know the date) the facility increased R1’s facility fees from $7,500.00 to $9,000.00. W1 stated that prior to billing him/her, staff did not provide him/her with written notice. On September 30, 2025, LPA Manuel Monter interviewed Staff S4 & Current Memory Care Director, Norlynn Peterson. S4 stated when the facility notices residents now have a higher level of care, they will notify the staff. S4 stated they will then inform the staff of the updated care needs of said resident. S4 stated they will update the family regarding changes in care and the changes of cost as well. S4 stated ultimately the family has to agree. S4 stated if a residents level of care does go up, they naturally the residents cost of care would increase. Page 4 Out of 5. On October 6, 2025, LPA Monter interviewed Witness W1. W1 stated regarding the change in the fees, that he/she was informed by the staff that R1 had a higher level of care. W1 stated he/she was told the change of fees was for the level of care from level 1 to level 3. W1 did acknowledge that R1 was declining. W1 stated R1 began to show wandering behaviors when he/she moved into the facility. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 5 Out of 5. END OF REPORT.