Records reviewed indicated that staff have adequate training. Review of staff schedule indicated that there are staff scheduled to work to meet the residents in care needs. Interviews with Administrator, staff and residents indicated that staff are able to complete their daily tasks and assist all residents in care with their needs. Therefore, the allegation insufficient staffing is unsubstantiated.

Facility is not arranging transportation to doctors appointments

Interviews conducted indicated that administrator was assisting in scheduling transportation for doctors appointments. There were a handful of times that the third party transport company cancelled last minute causing the resident to miss their scheduled appointment. Administrator or facility staff are able to assist with taking residents to their appointments. Therefore, the allegation facility is not arranging transportation to doctors appointments is unsubstantiated.

Medication mismanagement

Records reviewed indicated that sodium tablets were prescribed but then discontinued in November 2025 by Resident R1’s primary care physician (PCP). Facility was using an updated medication list signed by R1's physician as reference to the medications given. Facility accurately discontinued the medications as requested by PCP. Interviews conducted indicated that resident R1 was willing and able to take their medications and does not have any refusals of medications. Therefore, the allegation medication mismanagement is unsubstantiated.

Facility not providing a safe environment

Records reviewed indicated that R1 and R3 were in a verbal altercation on 11/16/2025. No injuries were noted per incident report. Interviews indicated that staff are providing a safe environment for residents in care. Observations indicated that residents are safe and being taken care of by staff at the facility. Therefore, the allegation of facility not providing a safe environment is unsubstantiated.

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Records indicated that there have not been any elopements from the facility. Resident R4 is considered an unsafe wandering risk but has not left the facility unattended while is care. Interviews conducted indicated that there have not been any elopements from the facility. Therefore, the allegation resident has wandered away from the facility is unsubstantiated.

Resident's personal items were not safeguarded

Interviews conducted indicated that when resident R1 moved out of the facility 02/03/2026, their personal belongings remained at the facility until 03/11/2026. On 03/11/2026, R1’s belongings were picked up, although one box was left behind by mistake. Therefore, the allegation resident's personal items were not safeguarded is unsubstantiated.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.

Observations made indicated that facility has the required two day perishable and seven day non-perishable food supply on hand. Meals are provided and portion sizes are adequate. Interviews conducted indicated that meals are served three times a day and residents can request secondary portions of meals if they would like. Therefore, the allegation facility does not have sufficient food is unfounded.

Resident's personal items were not safeguarded

Interviews conducted indicated that when resident R1 moved out of the facility 02/03/2026, their personal belongings remained at the facility until 03/11/2026. On 03/11/2026, R1’s belongings were picked up, although one box was left behind by mistake. R1’s family contacted administrator and requested the missing items and they were found and belongings were given back to R1 and their family. Therefore, the allegation resident’s personal items were not safeguarded is unfounded.

Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.