The complaint alleged that the Licensed Vocational Nurse (LVN) keeps the residents’ medical files locked in the medication room. On July 16, 2026, the department interviewed the Administrator (A1), who stated that the Medical Technical Room should only be accessed by staff who are Med Tech and LVN. Only those staff members involved in assisting with medications require access to the Med Room. A1 also stated the facility has five Med Tech on site in case of emergency.

On November 11, 2025, the department interviewed ten staff members (S1-S10). All of them denied the allegation, stating that only Med Tech and LVN have access to the room. Same day the department interviewed three residents (R1-R3), all denied the allegation.

During interviews on July 16, 2026, five staff members (S1-S5) were questioned and denied the allegation. They confirmed that both Med Tech and LVN, as well as all care staff involved in medication administration, had access to residents' medical records in emergencies. They further stated that if someone did not assist with medications, there would be no reason for them to access the records. Additionally, the department interviewed 10 residents (R2-R11), all of whom stated that they believe the staff has access to their medical records. On the same day, the department toured the facility and observed the Med Tech and LVN in the Med Tech room.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is unsubstantiated.

Report continued on LIC9099C

The complaint alleged that facility management instructs caregivers, who are not qualified, to dispense medications. It also claimed that temporary agency staff members were asked to dispense medications without proper certification. On July 16, 2026, the department interviewed the Administrator, who denied these allegations, asserting that only Med Tech, LVN, and trained, certified caregivers are permitted to assist with medication administration. The facility reportedly does not hire temporary agency staff.

On November 11, 2025, the department interviewed ten staff members (S1-S10), all of whom denied the allegations and stated that only Med Tech dispense medications. Similarly, on November 11, 2025, the department spoke with three residents (R1-R3), all of whom also denied the allegations and confirmed that the Med Tech administer their medications.

In a follow-up interview on July 16, 2026, the department spoke with five additional staff members (S1-S5). Once again, all denied the allegations, reiterating that only Med Tech, nurses, and certified caregivers assist with medications. Concurrently, the department interviewed ten residents (R2-R11), all of whom denied the allegations, stating that Med Tech give them their medications. Furthermore, the department reviewed facility records, which indicated that three Med Tech are scheduled for each shift.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is unsubstantiated.

Report continued on LIC9099C

The complaint alleged that staff do not ensure that residents take their medications after they have been dispensed. On July 16, 2026, the department interviewed the Administrator (A1), who denied the allegation. A1 stated that the medication technicians ensure residents take their medications unless the residents refuse, and that they attempt to have the residents take their medications again later.

On November 11, 2025, the department interviewed ten staff members (S1-S10), all of whom denied the allegations and confirmed that medication technicians make sure residents take their medications. If a resident refuses to take their medication, the technicians will try again later. On the same date, the department interviewed three residents (R1-R3), all of whom denied the allegations. During a follow-up interview on July 16, 2026, the department interviewed five additional staff members (S1-S5), and once again, all denied the allegations. They reiterated that Med Tech, nurses, and certified caregivers ensure that residents take their medications. Additionally, the department interviewed ten residents (R2-R11), all of whom denied the allegations, stating that Med Tech provide their medications and help ensure they take them. The residents also mentioned that they do not refuse their medications.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is unsubstantiated.

Report continued on LIC9099C

The complaint alleged that a resident, who was previously able to ambulate, is now bedridden and experiencing hip pain. On July 16, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that facility staff regularly observed any changes in residents' conditions. A1 explained that staff would inform the nurses and Med Tech about any changes in residents' health, prompting them to notify the physician accordingly.

On November 11, 2025, the department interviewed ten staff members (S1-S10). All staff members denied the allegations, stating that if they noticed any changes in a resident's condition, they would inform the Med Tech to ensure that the residents receive proper care. Additionally, on November 11, 2025, the department spoke with three residents (R1-R3), all of whom denied the allegations. In a follow-up interview on July 16, 2026, the department again spoke with five staff members (S1-S5), and all of them reiterated their previous denials. They confirmed that if any staff members noticed changes in a resident's condition, they would notify the Med Tech and nurses.

Similarly, the department interviewed ten residents (R2-R11) on July 16, 2026, and all denied the allegations as well. Furthermore, the department reviewed resident R1's physician reports 2026, which indicated that R1 is neither bedridden nor on hospice care, and R1 able to care for R1 toileting needs.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is unsubstantiated.

The complaint alleged that bruises were observed on a resident's hip and leg. When this was reported to the Licensed Vocational Nurse (LVN), no action was taken. On July 16, 2026, the department interviewed the Administrator (A1), who denied the allegations and stated that the LVN would not ignore such a report. The Administrator explained that if residents are sick or injured, the facility contacts Medical Emergency to send them to the hospital or allows the nurses and medication technicians to assist the residents. If a resident does not have a prescription, they must call medical emergency for any pain or discomfort. On November 11, 2025, the department interviewed ten staff members (S1-S10), all of whom denied the allegations and affirmed that they ensure medical attention is provided to all residents in care. Similarly, on the same day, three residents (R1-R3) were interviewed, and they also denied the allegations, stating that the staff helps them when they need medical assistance.

In a follow-up interview on July 16, 2026, five additional staff members (S1-S5) were interviewed, and they once again denied the allegations, reiterating that the staff ensures residents receive the necessary medical attention. Concurrently, the department interviewed ten residents (R2-R11), all of whom also denied the allegations and confirmed that the staff assists them when they need medical help. On July 16, 2026, the department reviewed the facility's schedule for medication technicians, which indicated there were three Med tech working during the night.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is unsubstantiated.

The complaint alleged that the facility lacked sufficient personal protective equipment (PPE) supplies. On July 16, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that the facility had plenty of supplies, including masks, incontinence pads, wipes, hand sanitizers, and protective gloves.

During the same visit, the department interviewed five staff members (S1-S5), all of whom also denied the allegation and confirmed that the facility had a large supply of PPE. Additionally, the department interviewed ten residents (R2-R11), all of whom reported that when they requested masks or any PPE supplies, the facility provided them. On July 16, 2026, the department toured the facility and observed two rooms filled with incontinence and PPE supplies.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is unsubstantiated.

Allegation #7: Facility does not have sufficient staff at all times to meet resident needs.

The complaint alleged that the facility does not have enough staff to meet the residents' needs. On July 16, 2026, the department interviewed the Administrator (A1), who denied the allegation, stating, "I think we have too many staff for each shift." Additionally, the department interviewed five staff members (S1-S5), all of whom also denied the allegation.

Furthermore, the department interviewed ten residents (R2-R11), all of whom refuted the allegations, stating that help is always available when they need it, even during the night. During my visit to the facility, I observed several caregivers, medication technicians, and housekeepers actively working. The records reviewed by the department regarding shift schedules indicate that the facility has sufficient staff for the morning, afternoon, and night shifts. The department was unable to interview resident R1 due to R1's health conditions.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is unsubstantiated.

No deficiencies were cited.

An exit interview was conducted. A copy of this report was provided to the Assistant Administrator Diosdado Mangune