Allegation #1: Staff do not distribute a resident's medication as prescribed.

It has been reported that staff did not administered Resident #1 (R1’s) prescribed medication. Reports indicated the staff are not administering (R1’s) skin medication. No additional information has been provided regarding this matter.

On August 3, 2026, and August 4, 2026, between 9:30 AM and 01:20 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) staff members could not support this claim. Interviews with staff indicated that medications are administered according to physician orders documented on the Medication Administration Record (MAR). (S1-S3) denied missing doses or altering medication administration times and stated they follow facility medication procedures, including double-checking medication labels and documenting administration immediately after dispensing. (S2) indicated that (R1) does not have a prescribed skin medication from (R1’s) medical physician. (S2) mentioned that (R1) might not have been received prompt attention because (R1) refused or is out in the community, and this is noted on the (MAR).

On August 3, 2026, and August 4, 2026, between 10:15 AM and 12:45 PM, the Department interviewed residents identified as Resident #1 through Resident #7 (R1-R7). Six (6) out of the seven (7) residents could not support this claim. (R2-R7) interviewed did not reveal concerns regarding medication administration. No residents reported missing doses or receiving medications incorrectly.

(R1) mentioned that skin medication, pain reliever, and sleep aids were not administered on time. (R1) was unable to specify when these delays occurred or which staff were involved but confirmed that the timing of the prescribed medications does not align with (R1’s) schedule.

The Department reviewed the (R1’s) (MAR) (dated 07/01/26 through 07/31/26) records show the pain reliever and sleep aid medications as (R1) refusal or out in the community. It did not show discrepancies between physician orders and recorded administration. Centrally stored medication logs matched medication counts, and no irregularities were observed in the medication storage area. Additionally, an examination of the Medical Assessment for Resident Care Facilities (LIC 602A) dated April 28, 2026, the Service Plan (dated 05/29/26).

(Evaluation Report continues LIC 9099-C)

Allegation #2: Staff do not safeguard a resident's personal belongings.

It is alleged that the staff did not safeguard Resident #1 (R1's) personal belongings. Reports indicate that (R1's) belongings are missing, although the specific items have not been identified. No additional information has been provided regarding this matter.

On August 3, 2026, and August 4, 2026, between 9:30 AM and 01:20 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) staff members could not validate this claim. Interviews with staff revealed that residents' personal belongings are kept in their rooms, and staff only handle or remove items when assisting with cleaning or organization. Staff members (S2-S3) mentioned that items confiscated from (R1) included non-prescription supplements, skin ointment, an energy drink and a vape. The energy drink was removed because of (R1's) health issue.

On August 3, 2026, and August 4, 2026, between 10:15 AM and 12:45 PM, the Department interviewed residents identified as Resident #1 through Resident #7 (R1-R7). Six (6) out of the seven (7) residents could not corroborate this claim. (R2-R7) they have not witnessed belonging being taken, misplaced or mishandled. Furthermore, they did not have concerns about staff failing to safeguard belongings. No resident stated that their personal items had been taken, lost, or handled inappropriately by staff.

(R1) reported that staff took personal items like vitamins, ointments, and drinks and did not return them. (R1) mentioned that family members brought these items in during visits and did not have prescriptions for them.

The Department reviewed (R1's) Residency Lease Agreement, dated May 29, 2026. On page 38, under the section titled "Loss or Damage of Personal Property," it states, "We encourage residents to purchase insurance for their belongings, as the facility cannot guarantee the safety of personal property." This section includes (R1's) acknowledgment signature. Further review of Resident Personal Property and Valuables LIC 621 (dated 05/07/26) did not have any personal property or valuable items listed.

On August 3, 2026, the Department inspected (R1's) room and found personal belongings organized and intact, with no signs of tampering or neglect.

(Evaluation Report continues LIC 9099-C)

Allegation #3: Staff do not assist resident with showering.

It is alleged that staff do not assist Resident #1 (R1) with showering. Reports indicated that (R1) is not given enough time to shower or it is not done promptly. No additional information has been provided regarding this matter.

On August 3, 2026, and August 4, 2026, between 9:30 AM and 01:20 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) staff members could not validate this claim. Interviews with staff indicated that residents are assisted with bathing according to their Services Plan. Staff reported that the (R1) receives regular assistance with showering. (S2-S3) stated that (R1) receives bathing assistance two times per week, specifically on Monday and Wednesday, between 6 AM and 2 PM. (S2-S3) denied refusing or failing to assist the resident with personal hygiene care.

On August 3, 2026, and August 4, 2026, between 10:15 AM and 12:45 PM, the Department interviewed residents identified as Resident #1 through Resident #7 (R1-R7). Six (6) out of the seven (7) residents could not support this claim. (R2-R7) interviewed did not reveal concerns regarding bathing assistance. No resident reported being denied help with showering or being left without necessary personal care.

The Department reviewed facility’s Shower Schedule, Medical Assessment for Resident Care Facilities (LIC 602A) dated April 28, 2026, the Service Plan (dated 05/29/26) and Notes & Incidents – Resident Summary (dated 05/30/26 through 08/03/26). Records showed that staff assisted the resident with showering consistently with the (R1’s) care plan. No missed bathing entries or gaps in documentation were found. During the visit on August 3, 2026 and August 4, 2026, the Department observed the resident to appear clean and appropriately groomed.

Based on interviews, record review, and observations, there was 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 allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

No deficiencies cited.

An exit interview was conducted with Robert Jakini, and copies of the reports were provided.