complaint·November 14, 2025

LPA Pascua reviewed facility records which corroborate that there are currently no residents with pressure injuries while in care. Based on the information gathered, there is not sufficient evidence to prove that the residents developed pressure injuries while in care. Allegation: Staff allow resident to be left in soiled clothing for extended periods of time. During the course of this investigation, this LPA conducted interviews with facility staff and residents. Based on interview with facility staff it was denied that residents are left in soiled clothing for an extended period of time. In addition, facility staff state that each resident is seen at minimum every 2 hours. Facility staff state that residents are also changed as needed according to their care plans. An interview with 5 residents were conducted. 5 out 5 residents denied being left in soiled clothing for an extended period of time. Based on the information gathered, there is not sufficient evidence to prove that staff allow resident to be left in soiled clothing for extended periods of time. Allegation: Staff do not ensure medications are dispensed as prescribed Based on interviews, record reviews and observation it was determined that the residents have been receiving medications as ordered and on time for July 2025-current. Additionally, LPA Pascua observed medications stored at facility to match physician orders and medication dispensing logs. LPA Pascua interviewed 2 staff members, 2 out of 2 staff members stated that medication is given per doctors orders. 2 out of 2 staff members also state that medication logs are audited by the facility care director on a weekly basis to ensure that medication will match with the count of medication available. 2 out of 2 staff membered both reported that they watch residents to ensure that their medication was taken. Record review also revealed that medications are documented appropriately to indicate when medication is taken or refused. Based on facility files LPA Pascua did not observe any substantial evidence that presented that facility staff was not providing medication as prescribed. Allegation: Licensee does not prevent staff from smoking inside the facility. It was alleged that the Licensee does not prevent staff from smoking inside the facility. Based on interviews conducted, it was denied that any staff smoke inside the facility. An interview with 5 staff members was conducted. 5 out 5 deny seeing anyone smoke inside the facility have any knowledge of anyone smoking inside. 5 out 5 staff member state that they would not smoke inside the facility. An interview with 5 residents was conducted. 5 out 5 residents deny seeing staff members smoke inside the facility. Based on the information gathered, there is not sufficient evidence to prove that the licensee does not prevent staff from smoking inside the facility. Allegation: Staff are not capable of performing assigned tasks due to intoxication while at the facility It was alleged that the facility staff are not capable of performing assigned tasks due to intoxication while at the facility. Interviews with 5 staff members were conducted, it was denied that any staff have been intoxicated, have come to work intoxicated and have seen anyone intoxicated. An interview with 5 residents was conducted. 5 out 5 residents deny seeing staff members incapable of doing their job due to intoxication. Based on the information gathered, there is not sufficient evidence to prove that the facility staff are not capable of performing assigned tasks due to intoxication while at the facility. Allegation: Staff do not follow residents prescribed dietary plans During the course of this investigation, this LPA conducted interviews and reviewed facility records. Based on interviews conducted, it was denied that staff do not ensure that staff follow resident’s dietary plans. An interview with 2 residents with dietary restrictions were conducted. It was denied by both residents that they do not get their prescribed dietary plans. In addition, it was stated that these plans were implemented and planned with the facility and themselves. A review of the resident’s records shows that the facility and their staff have followed the residents dietary plans and parameters. Based on the information gathered, there is not sufficient evidence to prove that the facility staff do not follow residents prescribed dietary plans. Allegation: Staff do not ensure residents personal hygiene needs are being met During the course of this investigation, this LPA conducted interviews with facility staff and residents. Based on interview with facility staff it was denied that staff do not ensure resident’s personal hygiene needs are being met. In addition, facility staff state that each resident is seen at minimum every 2 hours. Facility staff state that residents are also changed as assisted according to their care plans. An interview with 5 residents were conducted. 5 out 5 residents denied that their hygiene needs are not being met. Based on the information gathered, there is not sufficient evidence to prove that facility staff did not ensure residents personal hygiene needs are being met. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.