Allegation: Staff mismanaged resident’s medications.

It is alleged that staff mismanaged Resident #1's (R1’s) medications. Reports indicate that (R1) missed a scheduled dose of medication on one occasion. Additional details regarding the circumstances of this incident were not provided.

On August 24, 2026, between 09:45 AM and 3:32 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not support this claim. Interviews with staff consistently reported that all medications are administered according to physician orders, logged daily, and stored securely. (S1-S5) confirmed their lack of awareness of any incidents involving missed doses, medication errors, or improper handling of (R1’s) medications.

On August 24, 2026, between 10:05 AM and 11:38 AM, the Department interviewed residents identified as Resident #2 through Resident #10. Eight (8) out of nine (9) residents could not corroborate this claim. According to reports from (R2-R9), there have been no incidents related to missed doses, medication errors, or improper medication handling.

(R1) was unavailable for an interview because the resident passed away in the hospital on August 20, 2026.

On August 14, 2026, between 1:10 PM and 01:22 PM, the Department interviewed a witness member identified as (R1’s) responsible party, as Witness #1 (W1). (W1) reported incidents related to (R1’s) care based solely on (R1’s) account. However, (R1) could not provide any specific dates, times, types of medication, or names of those involved.

The Department reviewed (R1’s) Medication Administration Records (MAR) and Centrally Stored Medication records for the period of (07/01/26 through 08/13/26. All records were complete, legible, and showed no evidence of missing doses or incorrect administration. Physician orders on file matched the medications listed on the (MAR). No discrepancies were identified between medication labels, logs, or documentation.

During the visit on August 13, 2026, the LPA observed that (R1’s) medications were stored in the locked medication cart/room in a manner consistent with Title 22 requirements.

(Evaluation Report continues LIC 9099-C)

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.

Allegation: Staff handled resident in an inappropriate manner.

It is alleged that staff handled Resident #1 (R1) in an improper manner. Reports indicate (R1) was placed in bed forcefully by staff. No further details regarding the circumstances of this incident were provided.

On August 24, 2026, between 09:45 AM and 3:32 PM, the Department interviewed staff members identified as Staff #1 through Staff #4 (S1-S5). Four (4) out of the five (5) staff members could not validate this claim. (S1) stated that there have been no incidents of (R1) being handled inappropriately. (S1-S5) denied handling (R1) in any rough, forceful, or inappropriate way. All staff confirmed they used approved techniques to assist residents with transfers, mobility, and daily activities.

On August 24, 2026, between 10:05 AM and 11:38 AM, the Department interviewed residents identified as Resident #2 through Resident #10. Nine (9) out of nine (9) residents could not corroborate this claim. None of the individuals from (R2-R10) reported witnessing any inappropriate physical interactions between staff and residents.

(R1) was unavailable for an interview because the resident passed away in the hospital on August 20, 2026.

On August 14, 2026, from 1:10 PM to 1:22 PM, the Department conducted an interview with a witness identified as the responsible party for (R1), as Witness #1 (W1). (W1) detailed incidents concerning (R1’s) care based solely on (R1’s) description. (W1) could not remember specific dates, times, or names of individuals involved.

The Department reviewed personnel files and found current training in Resident Rights, Personal Care, and Safe Transfer Techniques. No incident reports regarding improper physical handling of (R1) were found for the relevant time period.

During the visit on August 13, 2026, the LPA observed staff assisting several residents with transfers, ambulation, and routine care. Staff were observed to be gentle, respectful, and consistent with Title 22 regulations and facility policies. No inappropriate handling was observed at any time.

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.

(Evaluation Report continues LIC 9099-C)

It is alleged that staff failed to ensure that Resident #1 (R1) was treated with dignity and respect. Reports indicate that the resident is not treated with dignity and respect during care. Additional details regarding the circumstances of this incident were not provided.

On August 24, 2026, between 09:45 AM and 03:32 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Three (3) out of the five (5) staff members could not support this claim. Interviews with Staff #1 and Staff #4 (S1 and S4) had knowledge of an incident involving (R1) and staff improper behavior as it was reported to them by (R1) and in which (S1) followed up with an internal investigation into the incident.

Staff #5 (S5) denied ever speaking rudely to (R1) or ever refusing to provide care services. (S5’s) statements are consistent with statements (S5) had given during the facility's internal investigation.

Staff #6 (S6), who had witnessed (S5) speaking offensively to (R1) during an internal investigation, was unavailable for an interview with the Department and did not respond to phone calls.

On August 24, 2026, between 10:05 AM and 11:38 AM, the Department interviewed residents identified as Resident #2 through Resident #10. Nine (9) out of nine (9) residents could not support this claim. All residents interviewed expressed they had not seen any incidents of disrespectful treatment towards themselves or other residents.

(R1) was unavailable for an interview because the resident passed away in the hospital on August 20, 2026.

On August 14, 2026, from 1:10 PM to 1:22 PM, the Department conducted an interview with a witness identified as the responsible party for (R1), as Witness #1 (W1). (W1) recounted specific events related to (R1’s) care based entirely on (R1’s) account. (W1) was unable to recall particular dates, times, or the names of people involved.

The Department reviewed facility training records and confirmed staff had completed current training on resident rights, dignity, and respect. No incident reports or complaints regarding disrespectful treatment of (R1) were found in the facility’s files for the relevant period.

(Evaluation Report continues LIC 9099-C)

During the visit August 13, 2026, and August 24, 2025, the LPA observed staff engaging with residents during routine care and activities. Staff were observed addressing residents by name, speaking calmly and respectfully, and providing care consistent with regulatory requirements related to dignity, privacy, and personal rights. No interactions were observed that appeared disrespectful or in violation of Title 22 regulations.

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated.

No deficiencies cited.

An exit interview was conducted with Catherine Dacara, and copies of the reports were provided.