Allegation: Staff threatened to overmedicate resident in care

The details of the complaint alleged that facility staff threatened to overmedicate (R#1) while in care.

On April 23, 2026, at approximately 10:00 a.m., during the records review, the Department observed copies of the facility staff Inservice training documents for the year 2026. The Department noted that facility staff had completed a series of training courses, including training on residents’ rights and how to treat residents with dignity and respect.

On April 23, 2026, during an interview with the facility administrator (A#1), the Department asked (A#1) to explain the facility’s expectations for staff communication regarding medications and how the facility addresses any statements that could be interpreted as threatening or inappropriate. (A#1) stated that facility staff assist residents only with their regularly prescribed medications. Staff inform residents when it is time for medication, and if a resident refuses, staff document the refusal and do not force the resident to take the medication. (A#1) further stated that for medications such as morphine, facility staff are not permitted to administer them; those medications are administered solely by the hospice agency. In addition, the Department also asked (A#1) to describe the safeguards in place to prevent misuse of medications and ensure staff do not make statements implying misuse. (A#1) stated that medications are stored in a locked cabinet for safety, and staff follow physician orders and the “five rights” of medication administration. (A#1) stated that he has never heard any facility staff make statements threatening to overmedicate a resident in care.

On April 23, 2026, during interviews with witnesses (W#1) through (W#4), (4) out of (4) stated that they had not overheard staff discussing medications in a manner that seemed unusual or concerning. In addition, when asked whether they had conversations with staff about how medications are handled or administered to residents, (4) out of (4) stated that the staff take care of the residents’ medication needs and follow the prescribed orders.

Evaluation Report continues LIC 9099-C

On April 23, 2026, during interviews with residents in care (R#2) through (R#3), (2) out of (2) residents stated that they had not heard staff talking about medications in a way that made them feel uncomfortable or worried. When asked how staff usually communicate with them or others about medications or medical care, (2) out of (2) residents stated that staff are very professional and responsible.

On April 22, 2026, at approximately 10:00 a.m., the Department was unable to interview residents (R#4) through (R#6) due to their cognitive health conditions.

On April 23, 2026, during interviews with facility staff (S#1) through (S#2), (2) out of (2) staff stated that when residents or family members ask about medications, staff explain the medications the resident is taking; however, most residents already know what medications they are prescribed. When asked whether they had ever heard any staff member make statements about combining medications or using medications in a way that could be interpreted as threatening, joking, or inappropriate, (2) out of (2) staff stated they had not.

Allegation: Staff did not prevent resident from leaving the facility unassisted

The details of the complaint alleged that facility staff did not prevent (R#1) from leaving the facility.

On April 23, 2026, at approximately 10:00 a.m., during the records review, the Department observed a copy of (R#1)’s Medical Assessment for Residential Care Facilities for the Elderly (RCFE), dated March 30, 2026. The Department noted that the assessment indicated (R#1) was non‑ambulatory and bedridden due to their physical and mental condition.

On April 23, 2026, during interviews with witnesses (W#1) through (W#4), (4) out of (4) stated that they had never seen or become aware of any resident being outside the facility without staff nearby during their visits. When asked how the facility monitors residents’ movements or manages access to exit doors, (4) out of (4) stated that the facility does a great job monitoring the residents.

On April 22, 2026, at approximately 10:00 a.m., the Department was unable to interview (R#1), as the resident passed away on April 14, 2026.

On April 23, 2026, during interviews with residents in care (R#2) through (R#3), (2) out of (2) residents stated that they had not seen any residents outside the building without staff present, noting that staff are always aware of everyone in the facility. When asked whether doors and exits are watched or checked by staff during the day and night, (2) out of (2) residents stated that, to their knowledge, they are.

On April 22, 2026, at approximately 10:00 a.m., the Department was unable to interview residents (R#4) through (R#6) due to their cognitive health conditions.

On April 23, 2026, during interviews with facility staff (S#1) through (S#2), (2) out of (2) staff stated that they monitor residents by regularly checking on them and ensuring that exit doors remain secured. Staff reported that the residents in care are not ambulatory in a physical sense, which further reduces the likelihood of residents attempting to leave the facility unassisted. When asked whether they had ever observed a resident outside the building without staff present or noticed any issues with exit doors not being secured, (2) out of (2) staff stated they had not.

The details of the complaint alleged that facility staff refused to maintain (R#1) clean.

On April 23, 2026, at approximately 10:00 a.m., during the records review, the Department observed a copy of (R#1)’s appraisal dated March 24, 2026. The appraisal documented that (R#1) required assistance with multiple personal-care tasks, including help with bathing, help with dressing, hair care, and personal hygiene, and help in transferring in and out of bed. The appraisal further indicated that (R#1) required toileting assistance, continence care, and assistance in incidental health and medical care, reflecting a high level of dependency for daily cleaning and hygiene needs.

On April 23, 2026, during an interview with the facility administrator (A#1), the Department asked (A#1) to describe the facility’s expectations for staff response when a resident, including (R#1), is found soiled or in distress, and how the facility ensures timely hygiene assistance is provided. (A#1) stated that facility staff conduct checks on residents every four hours and as needed to prevent residents from becoming soiled. In addition, when asked whether (R#1) or any other resident in care had ever been left in a soiled condition for an extended period, (A#1) stated, “I don’t think so.”

On April 23, 2026, during interviews with witnesses (W#1) through (W#4), (4) out of (4) stated that they had never observed any resident who appeared to need hygiene assistance, such as being soiled or requiring cleaning, during their visits. When asked how staff responded to residents’ hygiene needs, (4) out of (4) witnesses stated they had never seen a situation requiring staff intervention. When asked whether they had heard staff make comments about a resident’s condition.

On April 22, 2026, at approximately 10:00 a.m., the Department was unable to interview (R#1), as the resident passed away on April 14, 2026.

On April 23, 2026, during interviews with residents in care (R#2) through (R#3), (2) out of (2) residents stated that when they or other residents need help with cleaning, bathing, or changing, staff respond very quickly. When asked whether they had ever seen a resident who needed cleaning or hygiene care but did not receive assistance right away, (2) out of (2) residents stated they had not.

On April 23, 2026, during interviews with facility staff (S#1) through (S#2), (2) out of (2) staff stated that when a resident is found soiled or in need of hygiene assistance, staff are expected to change the resident as soon as they observe the need. Staff reported that they check on residents every couple of hours, and some residents can verbally inform staff when they need to be changed. In addition, when asked whether they had ever observed or been aware of a situation in which a resident needed cleaning and staff did not provide care right away, or in which staff made comments about a resident’s condition, (2) out of (2) staff stated they had not.

Allegation: Staff sleep at the facility while on shift

The details of the complaint alleged that facility staff are sleeping while on shift.

On April 23, 2026, at approximately 10:00 a.m., during the records review, the Department observed a copy of the facility’s staff schedule for April 2026. The Department noted that the schedule reflected 24-hour staffing coverage, with one staff member assigned to the 7:00 a.m. to 7:00 p.m. shift, one staff assigned to the 8:00 a.m. to 5:30 p.m. shift, and one staff assigned to the 7:00 p.m. to 7:00 a.m. overnight shift each day. The schedule showed consistent staffing patterns throughout the month, with no gaps in overnight coverage.

On April 23, 2026, during an interview with the facility administrator (A#1), the Department asked (A#1) to describe the systems the facility has in place to ensure staff remain awake, alert, and available to residents—including (R#1)—throughout their shift. (A#1) stated that the facility has 24-hour awake staff, and that staff are “always awake and checking on residents.” In addition, when asked whether (A#1) had ever observed or heard of facility staff sleeping during their work hours, (A#1) stated, “Not at all.”

On April 22, 2026, at approximately 10:00 a.m., the Department was unable to interview (R#1), as the resident passed away on April 14, 2026.

On April 23, 2026, during interviews with residents in care (R#2) through (R#3), (2) out of (2) residents stated that they had never noticed staff who appeared asleep, tired, or not paying attention during their shift. When asked whether staff respond quickly when assistance is needed at night or in the early morning, (2) out of (2) residents stated that staff do respond quickly.

On April 22, 2026, at approximately 10:00 a.m., the Department was unable to interview residents (R#4) through (R#6) due to their cognitive health conditions.

On April 23, 2026, during interviews with facility staff (S#1) through (S#2), (2) out of (2) staff stated that they are expected to remain awake and alert throughout their shifts, noting that “there is always something going on” that requires staff attention. Staff reported that they are required to always remain available to residents. In addition, when asked whether they had ever observed staff who appeared to be asleep, inattentive, or unavailable during their shift, (2) out of (2) staff stated they had not.

Evaluation Report continues LIC 9099-C

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the Complaint Report was given to John Paul Atencio/Administrator.