complaint·August 15, 2025

(PAGE 2) Report continued from LIC 9099... During todays visit the LPA conducted a medication audit for Resident #1 (R1) at 10:09 a.m., A wellness check and a brief interview at 11:18 a.m. and obtained copies of pertinent documents relevant to the investigation. LPA reviewed all of R1's medications starting at 10:09 a.m. Medications are centrally stored in a locked closet located in the hallway adjacent to the dining room. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be given according to the physician order via G-Tube as prescribed and documented on the centrally stored medication and destruction records. No errors observed. On 07/25/2025 starting at 11 a.m. LPA conducted eight (8) in-person interviews, with three (3) residents including R1, two (2) family visitors, four (4) staff including the Licensee Representative, and Administrator, attempted four (4) telephonic interviews, at 12:39 p.m. conducted a file review for R1 and obtained copies of pertinent documents relevant to the investigation. On 07/30/2025 LPA conducted two (2) telephonic interviews at 3:15 p.m. with R1’s conservator and at 2:41 p.m. with R1’s son. On the allegation Staff is interfering with a resident's visitations it is the concern of the Reporting Party (RP) that the facility staff are limiting R1’s telephone calls by denying access to R1’s son. To investigate this complaint, LPA conducted eight (8) in-person interviews, with three (3) residents including Resident #1 (R1), two (2) family visitors, four (4) staff including the Licensee Representative, and Administrator, attempted four (4) telephonic interviews, at 12:39 p.m. conducted a file review for R1 and obtained copies of pertinent documents relevant to the investigation. On 07/30/2025 LPA conducted two (2) telephonic interviews at 3:15 p.m. with R1’s conservator and at 2:41 p.m. with R1’s son. Resident interviews including R1 indicated that residents were unable to provide information due to limited cognitive awareness. LPA observation revealed that during the initial visit conducted on 07/25/2025 LPA made three (3) separate attempts at 11:52 a.m., 12:31 p.m. and at 1:31 p.m. to speak / interview R1. Two (2) of the three (3) attempts R1 was sleeping. At 12:46 p.m. the LPA observed R1 to receive a phone call from their son and staff assisted with the phone call. Interviews with two (2) family members / visitors revealed that they visit on a daily basis and have not had any concerns or issues with visitation. The staff and Administration team have not restricted visits and are very flexible with visiting hours. Visitors primarily conducted in person visits and have yet to attempt or conduct a telephonic visit / phone call. It was noted that, due to limited cognitive awareness, they believe the resident would be unable to understand the components of accepting a phone call or handling the phone in general. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099... Furthermore, it was observed that when the facility receives a phone call, staff answer the call and bring the phone to R1. While the caller's identity remains unknown, they have witnessed staff deliver the phone to R1. Interviews with four (4) staff including the Licensee Representative, and Administrator revealed that they ensure compliance, emphasizing adherence to resident’s personal rights. R1 receives daily phone calls from their son. When R1’s son calls the staff check if R1 is awake before taking the phone to R1. If awake, R1 may engage in brief communication, usually once or twice a day but there are times when R1 does not respond. R1’s son will typically call four (4) to five (5) times per day. R1 has occasionally declined to speak with son, either by handing the phone back or verbally indicating they do not wish to speak. Staff consistently assist with incoming phone calls and have never failed to assist with phone calls. Additionally, staff make efforts to support phone calls unless there is an emergency, or they are momentarily occupied. In such cases, callers are informed and asked to call back. Interviews with R1’s conservator revealed that Based on available notes, the agency has not encountered any issues contacting or visiting R1, nor have they experienced resistance from facility staff. Interview with R1’s son revealed that they shared concerns about R1’s condition, stating that during a phone call earlier that day, R1 was coughing and seemed disoriented. It was noted that during recent conversations, R1 appeared disengaged and had difficulty speaking, often coughing. Additionally, it was noted by staff to the son that R1 sleeps approximately half of the time. Out of 5–6 attempted calls, staff were only able to assist with 2–3 calls; during the remaining calls, staff stated that R1 was asleep. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff is interfering with a resident's visitations is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report provided.