complaint·January 12, 2026

Page 2 Staff verbally intimidated resident. – UNSUBSTANTIATED It was reported that Staff 1 (S1) tried to force Resident 1 (R1) into taking a nebulizer treatment that R1 does not want to take. Also reports that S1 bosses R1 around and tries to “make deals” with R1 so R1 will take the treatment. R1 feels verbally “beat up.” LPA reviewed MAR for October 2025 which includes a prescription for a nebulizer treatment three times per day. The MAR has multiple documented refusal dates by R1 for this medication. R1’s Physician’s Report notes that R1 tends to forget to take their medications and requires assistance with providing medication at the appropriate times. R1 stated they do oxygen at night and don’t need a nebulizer. If R1 refused the treatment some staff would get mad at R1 and some would just say that was not ok. R1 stated staff treat them good at the facility. Staff stated they told R1 that it’s important to take the medication that their doctor prescribed to them, and staff are concerned If R1 won’t take the treatment. Administrator stated that R1 likes to refuse their nebulizer treatment often. Facility staff try to time the treatments and explain to R1 that they really need it and try to re-direct. This allegation is unsubstantiated. Page 3 Staff withheld resident’s personal belongings as punishment. – UNSUBSTANTIATED It was reported S1 withheld cigarettes from R1 because they would not take their nebulizer treatment. R1 stated their doctor wants them to quit smoking. The facility cut R1’s cigarettes back to one per hour when R1 went on oxygen. R1 states they were getting as many as they needed but they tapered them off to one an hour. Staff stated R1 gets one cigarette per hour and R1 forgets that they receive their hourly cigarette. Staff denies withholding cigarettes from R1. Administrator stated staff have not been withholding cigarettes from R1 and the facility has started asking residents to initial every time staff give them a cigarette. This allegation is unsubstantiated. This agency has investigated the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Julie Wilcox.