Staff did not meet resident's toileting needs- Based on interviews with client, reporting party, and staff. On 7/29/2025 Clinet (C1) was on the way to an outing in Van when C1 urinated in the van on the way to the outing. Staff did have extra clothing for C1 and changed into that clothing. Staff interviewed stated that C1 was too excited to stop to use the restroom, C1 wanted to get to the outing. LPA Lund interviewed C1 who stated that C1 was very eager to get to the outing that day and urinated by accident, but staff had extra clothing for C1. C1 does own Activities of Daily Living (ADLS) and this normal occurrence for C1.

Based on interviews with client, reporting party, and staff the information provided, it was unclear if staff did not meet resident's toileting needs therefore the allegation was deemed UNSUBSTANTIATED.

Staff does not allow resident's to purchase personal items- Based on records reviewed, interviews with clients in care, reporting party, and staff. LPA reviewed three clients P & I Cash Log from 9/1/2025 through 10/8/2025 and were able to purchase items they wanted. Staff interviewed stated that clients in care able to purchase things if they want as long they have the money on their P&I. Clients interviewed stated that they are allowed to get things they want if they have the money.

Based on records review, interviews with clients, reporting party, and staff the information provided, it was unclear if staff does not allow resident's to purchase personal items therefore the allegation was deemed UNSUBSTANTIATED.

Staff does not afford residents privacy- Based on records reviewed, interviews with clients in care, reporting party, and staff. Client (C2) has a Client Sign- Out Procedure as well with the same list is able to talk to over the facility phone with same individuals. C2 is able to go in C2’s room and use the phone and has the privacy that C2 needs. Staff interviewed stated that C2 get the privacy that C2 needs. Clients interviewed stated that staff are great and give the privacy they need.

Staff yell at residents- Based on records reviewed, interviews with clients, reporting party, and staff. LPA Lund review facility Required Reporting of Dependent Adult Abuse for staff & 40 hours of 14 training courses for staff orientation. LPA Lund interviewed staff who stated they have never seen any staff yell at any clients in care, if they had they would notify management immediately. LPA Lund interviewed clients in care who stated no staff have yelled at them.

Based on records review, interviews with clients, reporting party, and staff the information provided, it was unclear if staff yell at residents, therefore the allegation was deemed UNSUBSTANTIATED.

Staff mismanage residents' medications- Based on records reviewed, interviews with clients, reporting party, and staff. LPA Lund reviewed three clients Medication Administration Record (MARS) from 8/1/2025 through 9/30/2025 and were in compliance. The facility reported no medication errors through this time. LPA Lund reviewed staff trainings in 7 Rights of Medication Administration also Medication Procedure & MAR Documentation. Staff interviewed stated they have no problems giving medications to clients in care. Clients in care stated that they take the medications that staff give to them.

Based on records review, interviews with clients, reporting party, and staff the information provided, it was unclear if staff mismanage residents' medications therefore the allegation was deemed UNSUBSTANTIATED.

Based on records review, interviews with client, reporting party, and staff the information provided, it was unclear if facility is operating out of ratio therefore the allegation was deemed UNSUBSTANTIATED.

The Department (CCLD) has found the allegations. Unsubstantiated.

A finding that the complaint allegation(s) are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. Exit interview was conducted with and report left.