Investigation revealed the following:

On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of 10 staff interviewed stated residents have not been handled in a rough manner that could have resulted in injuries. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the interviews conducted 2 residents stated staff members have not handled them in a rough manner causing injury. The remaining 8 residents were unable to engage in a clear conversation.

2 Allegation: Staff inappropriately restrained resident

On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of 10 staff members stated residents have not been inappropriately restrained in any way. LPA requested any special incident reports during the visit, and none could be provided because there were no incidents to report regarding restraining residents. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the interviews conducted 2 residents stated staff members have not restrained them in any way. The remaining 8 residents were unable to engage in a clear conversation.

Continued...

On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff does provide a safe and comfortable environment for residents. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members have provide a safe and comfortable environment. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA observed the residents to be in a safe and comfortable environment and no health and safety concerns were observed.

4 Allegation: Staff did not provide residents with privacy

On 5/12/2025, LPA conducted interviews with Staff 1 -Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff does provide residents with privacy while assisting with showers and any ADL's requiring privacy. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members have provide them with privacy. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA didn’t observe any residents’ rights being violated.

5 Allegation: Staff mismanaged residents’ medication

On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff has not mismanaged residents’ medication. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated staff members have provided them with their medications daily. The remaining 8 residents were unable to engage in a clear conversation. On 5/12/2025 LPA observed R1 Medication Administration Records (MARS) and based on LPA observations it appeared that R1s medications had been administered as prescribed by their physicians.

Continued...

On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated residents are not left unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence issues are addressed or as needed. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members help them with their Assistance with Daily Living (ADLS) as needed or when asked. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting incontinence assistance from staff members.

7 Allegation: Staff did not provide adequate food service

On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated the residents are provided adequate food service based on their dietary needs or modified diets. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated they get three (3) meals and snacks daily the remaining 8 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed the residents in care being fed and eating a balanced meal for breakfast -hot cereal, eggs, bacon and toast, Lunch- Baked pork chops, cornbread, mashed potatoes, and mixed veggies.

On 5/22/2025 LPA toured the kitchen and observed there to be a 5-day supply of perishables and a 7-day supply of non-perishable food items. Lunch served tuna casserole, green salad, green beans and cornbread, water, juice and coffee. There was a menu available for review that reflected meals served.

8 Allegation: Medications are not being stored properly

On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), 10 out of 10 staff members stated the medication room is locked when not in use. LPA observed the residents’ medications to be stored properly in the medication room locked in drawers inaccessible to the residents. LPA also observed the Medication Technicians (MEDTECHS) using their keys to open the medication drawers during the random audit of records/medications. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated they are not sure about medications being stored properly. Continued ..

On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff has not left residents unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence issues are addressed. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members help them with their Assistance with Daily Living (ADLS) as needed or when asked. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting incontinence assistance from staff members.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated.

An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.