Complaint·December 1, 2025

Page 2 of 2 LPA obtained documents including but not limited to death report and incident report for 1 resident and reviewed Centrally Stored Medication Records for 3 residents. On 09/29/25 LPA Yanez conducted a follow up complaint investigation visit and interviewed 1 staff and obtained pertinent resident documentation. On 10/10/25 LPA Yanez conducted a follow up complaint investigation visit and interviewed 5 additional residents. During the investigation the department interviewed 10 Residents (R1-R10) and 5 Staff (S1-S5). 9 out of 10 residents stated the facility staff have not been disrespectful or rude and have always treated them with dignity and respect. 1 out of 10 residents stated that the previous facility general manager was difficult to work with. During the investigation Resident (R1s) death report was reviewed and determined resident passed away from underline ailments and the death certificate states that the residents time interval between the onset and death was listed as years. 7 out of 7 staff stated they have not seen the medication cart unattended, the only time is when a Med-Tech is handing out medication, but it is locked when left unattended. 7 out of 10 residents stated that they get there medication on time and according to doctors order. 3 out of 10 resident stated they administer their own medication. During visit LPA Yanez observed staff administering medication to residents and 2 of 2 residents visited the Medication Room to get there noon medication, and Med Tech stated residents are diligent when its time for their medication to be administered. Page 3 of 3 LPA audited 6 residents Centrally Stored Medication Record and found all medication was administered according to doctors order. During the investigation the department reviewed an incident report with R1s fall dated 10/01/24 and fax cover sheet stating 3 pages that were faxed to the department on 10/01/24. On 12/01/25 the department has completed its investigation and found the above allegations Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. This report was reviewed with ADM Ida Gemignani-Stearns and a copy of the report was provided.