complaint·February 18, 2026

Based on records reviewed, interviews with staff, R1, Reporting Party and witness on the information provided, it was unclear if licensee does not ensure that resident's incontinence needs are met, therefore the allegation was deemed UNSUBSTANTIATED. Licensee confines resident to bed- LPA Lund reviewed facility records, interviewed staff, Reporting Party, Resident (R1), and witness. LPA Lund reviewed LIC 602A dated 10/17/2025 for R1 which states R1 is non- ambulatory. LPA Lund interviewed staff who stated that R1 does need guidance but can get up out of bed and wheelchair. LPA Lund interviewed R1 who stated that R1 can get up to R1 wheelchair or walk to a chair but can’t walk that far. LPA Lund interviewed witness who is there every day stated that staff help R1 out of bed but never confine to just the bed or wheelchair. R1 goes outside when it is nice or in the living room to watch TV. Based on reviewed facility records, interviewed staff, Reporting Party, R1 and witness, on the information provided, it was unclear if licensee confines resident to bed, therefore the allegation was deemed UNSUBSTANTIATED. Licensee confines resident to wheelchair- LPA Lund reviewed facility records, interviewed staff, Reporting Party, Resident (R1) in care and witness. LPA Lund reviewed LIC 602A dated 10/17/2025 for (R1) which states R1 is non- ambulatory. LPA Lund interviewed staff who stated that R1 does need guidance but can get up out of bed and wheelchair. LPA Lund interviewed R1 who stated that R1 can get up to R1 wheelchair or walk to a chair but can’t walk that far. LPA Lund interviewed witness who is there every day stated that staff help R1 out of bed but in never confine to just the bed or wheelchair R1 goes outside when it is nice or in the living room to watch TV. Based on reviewed facility records, interviewed staff, R1 and witness, on the information provided, it was unclear if licensee confines resident to wheelchair, therefore the allegation was deemed UNSUBSTANTIATED. Licensee yelled at resident- LPA Lund reviewed facility records, interviewed staff, R1 and witness. LPA Lund reviewed staff training, and all staff have been trained to know that they are mandated reporters and know how to report any abuse to Community Care Licensing (CCL). Staff stated they have taken the mandatory training and Dementia Care: Managing Challenging Behaviors. LPA Lund interviewed R1 who stated that staff are great and help with all needs. LPA Lund interviewed witness who stated staff help R1 with just about everything and never seen any staff yell or do anything to R1. Based on reviewed facility records interviewed staff, R1 and witness, on the information provided, it was unclear if licensee yelled at resident, therefore the allegation was deemed UNSUBSTANTIATED. Licensee pushed resident- LPA Lund reviewed facility records, interviewed staff, Resident (R1), Reporting Party and witness. LPA Lund reviewed staff training, and all staff have been trained to know that they are mandated reporters and know how to report any abuse to Community Care Licensing (CCL). Staff stated they have taken the mandatory training to work at the facility and know how to report any issues to management or to CCL. LPA Lund interviewed R1 who stated that staff are great and help with all needs. LPA Lund interviewed witness who stated staff help R1 with just about everything and never seen any staff yell or do anything to R1. Based on reviewed facility records interviewed staff, R1, Reporting Party and witness, on the information provided, it was unclear if licensee pushed resident, therefore the allegation was deemed UNSUBSTANTIATED. Licensee does not distribute resident's medications as prescribed – Based on facility records and interviews with staff, Reporting Party and witness. LPA Lund reviewed facility Medication Administration Records (MARS) 10/1/2025 through 11/30/2025 were completed and in compliance. Bristol Hospice orders medications for R1. LPA Lund interviewed witness who stated that she sees staff giving medications and believes that R1 get medications that R1’s supposed to get. Based on facility records and interviews with staff, Reporting Party and witness, on the information provided, it was unclear if licensee does not distribute resident's medications as prescribed, therefore the allegation was deemed UNSUBSTANTIATED. Licensee does not provide resident with adequate supervision, resulting in multiple falls - Based on facility records, interviews with staff and Resident (R1) and witness. Staff records show that the facility always had one staff member for the one resident in care at all times. LPA Lund did receive a Unusual Incident/Injury Report dated 10/12/2025 which states R1 was trying to get up and fall and had no injury. Administrator Olivia Perez stated that she notified hospice, POA and CCL of the fall. Staff do half hour checks on R1 to make sure R1 has not slipped out of bed. Based on facility records, interviews with staff and Resident (R1) and witness, on the information provided, it was unclear if Licensee does not provide resident with adequate supervision, resulting in multiple falls, therefore the allegation was deemed UNSUBSTANTIATED. Licensee does not maintain a centrally stored medication log for resident - Based on LPA’s Lund observation of the centrally stored medications on 10/28/2026 and interviews with staff and witness. LPA observed the medications to stored in a hallway closed locked and secured. LPA Lund interviewed Administrator Olivia Perez who states that she stores all medications in the hallway closet locked. Witness stated that she see staff taking medications from hallway closet. Based on LPA’s Lund observation of the centrally stored medications on 10/28/2026 and interviews with staff and witness, on the information provided, it was unclear if licensee does not maintain a centrally stored medication log for resident, therefore the allegation was deemed UNSUBSTANTIATED. As a result of this investigation, this Department finds the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegations may have happened or is valid, there is not preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and report left.