The complaint alleges that medications are prepared for residents in cups and left accessible to residents in care. During the initial complaint visit, LPAs toured the facility, looked in all common areas including kitchen cabinets and drawers, but did not observe any pre-prepared cups of medications as described in the complaint. Interviews with residents and staff revealed medications are given in the morning, at lunch, during dinner and at bedtime, as prescribed. Residents indicated the medication technician gives them their medications and waits until the resident takes their medications before leaving. No staff nor residents interviewed have seen pre-prepared medications left either with the resident or in a common area for administration at a later time. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time.

Allegation “Staff mismanaged residents’ records:”

It was alleged that residents are reported as “not participating” despite activity records showing otherwise and resident needs and quality of life are misrepresented to families. Staff interviewed indicated that at the time of the complaint all activities and activities of daily living (ADL) charting was conducted on an electronic device. During that time, the staff could mark each activity the resident completed on the device and add notes as applicable. Interviews revealed that staff would only mark activities they personally completed during their shift. No staff interviewed had heard of anyone at the facility mismanaging resident records or purposely misrepresenting resident needs. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time.

Allegation “Staff exposed residents in care to extreme outdoor heat:”

The complaint alleges that even during extreme temperatures, residents are taken outside to participate in activities. During the initial complaint visit, LPAs observed a group of residents in a shaded area on the outside patio participating in an activity. On the date of the initial visit, the high was 80 degrees Fahrenheit. Residents interviewed felt comfortable outside. Interview with staff and residents revealed that during heat

Continued on LIC 9099-C (p. 3)

Allegation “Staff denied medication assistance to residents in care:”

It is the concern of the complainant that there is only one (1) trained medication technician on each shift, who is responsible for medication assistance for all four (4) buildings in the facility, which isn’t sufficient to meet resident needs. Complainant further added that “requests for PRN (as needed) medications…are frequently ignored or denied.” LPA interviewed residents related to their medication needs, including PRN medications. All residents interviewed indicated they receive all their medications on time and as requested. One resident did state that all medications need to be prescribed by the physician, so the only time they were unable to receive a PRN medication is when it was not approved by their doctor; it was no fault of the facility. No residents interviewed reported concerns related to medications. Staff interviews revealed that although there used to be two (2) medication technicians scheduled during the day and evening shifts, the workload is manageable for one (1) person, as the facility census is also lower than it was previously. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time.

No citations issued. As this facility was closed due to a change of ownership on 11/18/2025, this report will be sent to the Licensee Representative via email and postal mail for signature.

The complaint alleges that staff are not properly trained. Interviews revealed that when a new staff member is hired, they begin training right away. The facility utilizes both an online training platform as well as hands-on training to meet both initial training and ongoing training requirements. LPAs Camara and Dulek reviewed training records for staff during the initial complaint visit and observed all five (5) staff files reviewed contained the twenty (20) hours of required annual trainings. However, it was observed that of 4 (four) direct care staff files reviewed, 3 (three) staff (S1, S2, and S3) did not have current first aid training and 2 (two) staff (S1 and S2) did not have current CPR training.

During the annual visit conducted concurrently with the initial complaint visit on 07/16/2025, a deficiency related to these training needs was issued, therefore no deficiency will be issued for this substantiated complaint allegation.

As this facility was closed due to a change of ownership on 11/18/2025, this report will be sent to the Licensee Representative via email and postal mail for signature.