During interview W1 reported that resident is over medicated. During interviews S3 and S4 stated they are the staff that take care of R1. R1’s medication is prescribed by physicians. LPA reviewed medication administration record (MAR) and observed all medicines given were taken for December 2025 and January 2026. LPA observed W3 was oriented during interview. W3 stated she was told she was over medicated but feels fine.

Allegation: Staff are not providing adequate food service to resident

During interview W1 reported that staff are not providing adequate food by giving resident soup all the time. LPA reviewed the physician’s report dated 10/31/2025, which indicates R1 requires food to be pureed due to diagnosis. LPA also reviewed facility’s menu that laid out what was to be eaten for the week and there was a variety of foods being served. S2 stated during interview that R1’s food is normally pureed, but R1 also eats food that is very soft. During interview R1 stated the staff will tell her what food is being pureed and if R1 doesn’t have a taste for that the staff will accommodate the request. R1 stated she does not have a problem with the food that is being served.

Allegation: Staff did not notify resident's authorized representative that resident went to the hospital

LPA reviewed documentation that indicated R1 has a court ordered conservator. LPA also reviewed the incident report dated 11/27/2025, that was submitted by S1, indicating the conservator was notified about the hospitalization of the R1. During interview with W2 on 1/2/2026, it was revealed that the authorized representative was notified about the hospitalization.

Continued on LIC9099C.

W1 stated during initial interview that staff did not safeguard resident’s clothing. W1 stated clothing was bought for R1 that should have been dry cleaned only and staff washed clothing. S1, S2, S3, and S4 stated all residents clothing is washed on site. S1 stated if clothing is to be dry cleaned the family would take care of that for the resident.

Allegation: Staff did not ensure resident was bathed by a female

W1 stated during interview that R1 was bathed by a male and W1 wasn’t sure if care plan states that can be done. S1 and S4 stated only females work on the side that R1 resides. R1 stated S3 assist her with bathing 2xs a week and more if she requests, and if S3 is not there S4 assist her with needs.

Allegation: Staff are inappropriately turning resident's phone off

W1 stated during interview that several times during visitation R1’s phone was found to be turned off, and he feels that staff are responsible. S3 and R1 stated during interviews that R1 has possession of her phone and staff does not touch it. During interview LPA observed R1 had her phone on her person.

Allegation: Staff are not allowing residents to watch TV

W1 stated during the interview that a male staff (unknown name) did not allow the residents to watch football because he was watching baseball. LPA observed during visit there was a television in two locations and there were only residents watching.

Allegation: Staff did not ensure resident had privacy

During interview W1 reported staff did not ensure R1’s privacy by a male staff

Continued on LIC9099C.

Allegation: Staff did not ensure resident received her PNI

During interview W1 stated staff is not ensuring resident is receiving PNI. W2 and W4 stated R1 has a payee that handles her finances. W4 stated during interview on 1/5/2026, that he has been the R1’s payee since June 2024. W4 also stated that R1 requested to save any money left over due to everything is paid for at the facility.

Based upon the interviews conducted during the investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of report was given.