On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of the 10 staff interviewed all stated that residents have not been handled in a rough manner that could have resulted in injuries. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not handled them in a rough manner. The remaining 8 residents were unable to engage in a clear conversation.

On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of 10 staff members stated that residents have not been inappropriately restrained in any way including R1. LPA requested any special incident reports during the visit, and none could be provided because there has not been any incidents to report pertaining to restraining any residents. LPA also searched the Departments of Social Services (DSS) database to confirm if there were any unusual incident reports (UIR) submitted which could not be found.

LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not inappropriately restrained them in any way. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA did not observe any residents being inappropriately restrained by the staff.

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On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff does provide a safe and comfortable environment for residents. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have provide a safe and comfortable environment for residents. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA observed the residents to be in a safe and comfortable environment and no health and safety concerns were observed.

4 Allegation: Staff did not provide residents with privacy

On 5/12/2025, LPA conducted interviews with Staff 1 -Staff 10 (S1–S10), Residents 1 through Resident 10 (R1–R10). 10 of 10 staff members stated staff does provide a safe and comfortable environment for residents providing them privacy while conducting showers and any ADL's requiring privacy. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members provide them with privacy the remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA didn’t observe any residents’ rights being violated by not providing privacy.

5 Allegation: Staff mismanaged residents’ medication

On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 of 10 staff members stated staff has not mismanaged residents’ medication. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated they don't believe their medication is mismanaged. The remaining 8 residents were unable to engage in a clear conversation. On 5/12/2025 and LPA observed R1 Medication Administration Records (MARS) and based on LPA observation it appeared that R1s medications had been administered as prescribed by their physicians.

6 Allegation: Residents are being left unattended for extended periods

On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 of 10 staff members stated staff has not left residents unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence issues are addressed. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that they get help when they need it, and the remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting incontinence assistance from staff members.

On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated the residents are provided adequate food service. LPA observed the residents in care being fed and eating a balanced meal for breakfast -hot cereal, eggs, bacon and toast, Lunch- Baked pork chops, cornbread, mashed potatoes, and mixed veggies. On 5/22/2025 LPA toured the kitchen and observed there to be a 5-day supply of perishables and a 7-day supply of non-perishable food items. Lunch served tuna casserole, green salad, green beans and cornbread,water,juice and coffee. There was a menu available for review that reflected meals served.

LPA conducted interviews with Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that they get three (3) meals and snacks daily the remaining 8 residents were unable to engage in a clear conversation.

8 Allegation: Medications are not being stored properly

On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), 10 out of 10 staff members stated the medication room is locked when not in use and LPA observed the residents medications to be stored properly in the medication room locked in drawers inaccessible to the residents. LPA also observed the Medication Technicians (MEDTECHS) using their keys to open the medication drawers during the random audit of records.

9 Allegation: Residents are not being changed in a timely manner.

On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 of 10 staff members stated they have not left residents unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence needs are met.

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Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated.