The department interviewed residents (R2-R5) about the allegation and 4 of 4 residents that were interviewed stated that they like the food they are being served by the staff. The department attempted to interview R1 but could not due to cognitive difficulties. The department interviewed witnesses (W1-W2) about the allegation, and they stated that the staff serves a variety of wholesome meals to the residents with many courses. They also state that they will occasionally supplement meals and bring other things for the resident. But overall, they are happy with the food being provided by the facility staff.

The department reviewed the Medical Assessment (Dated: 03/18/2026,10/15/2025, 9/17/2025), Appraisal/Needs Service Plan (Dated: 05/29/2026, 10/21/2024, 09/22/2025), and Menu and observed that some residents can eat regular food and others need their food pureed. The department reviewed the facility menu and observed that the facility serves a variety of fruits and vegetables, whole grains, proteins, dairy products, fish, and poultry for the residents. The department also observed food preparation for the residents and found that the meals looked nutritious, and the residents seemed to enjoy it.

Based on interviews, records reviewed, and observation, there is insufficient evidence to support the allegation that Staff do not ensure residents are served food of good quality. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Report Continued On LIC9099-C

The details of the complaint allege that facility staff do not serve adequate food portions for the residents to eat. On 8/19/2026, from 9:30am-1:00pm, the department interviewed staff (S1-S3), witnesses (W1-W2), and residents’ (R2-R5). The department attempted to interview resident (R1) but could not due to cognitive difficulties. 3 of 3 staff denied the allegation Staff does not ensure residents are served adequate portions of food. All staff (S1-S3) stated that they do serve adequate portions of food for the residents to eat. They also stated that some residents eat more than others depending on their medical diagnosis. Staff stated that some residents are on hospice and have a light appetite compared to other residents, but all residents are given adequate portions of food.

The department interviewed residents (R2-R5) about the allegation and 4 of 4 residents that were interviewed stated that they get enough food to eat and the food portions are large enough for them. The department attempted to interview R1 but could not due to cognitive difficulties. The department interviewed witnesses (W1-W2) about the allegation, and they stated that the staff does give adequate portions of food. They also stated that some residents may eat half the meal depending on their appetite and can’t eat large portions, though they may be served a large portion.

The department reviewed the Medical Assessment (Dated: 03/18/2026,10/15/2025, 9/17/2025), Appraisal/Needs Service Plan (Dated: 05/29/2026, 10/21/2024, 09/22/2025), Hospice Care Plan (Dated: 05/16/2026), and Menu and observed that some residents can eat regular food portions and others need their food pureed. The department toured the facility during breakfast and lunch and observed that the residents were served adequate food portions. While some residents ate their entire meal others did not. The department asked if the food was good and the residents stated yes that it was very good.

Based on interviews, records reviewed, and observation, there is insufficient evidence to support the allegation that Staff does not ensure residents are served adequate portions of food. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #3- Staff does not ensure resident receives assistance with personal grooming.

The details of the complaint allege that facility staff do not assist the resident with personal grooming. It was reported that staff do not groom the residents’ fingernails. On 8/19/2026, from 9:30am-1:00pm, the department interviewed staff (S1-S3), witnesses (W1-W2), and residents’ (R2-R5). The department attempted to interview resident (R1) but could not due to cognitive difficulties. 3 of 3 staff denied the allegation Staff does not ensure resident receives assistance with personal grooming. All staff (S1-S3) stated that they do assist the resident(s) with personal grooming. They state that they will trim and file the residents’ nails at no charge if they need to be trimmed and groomed. S1 stated that the only time they will not and leave it to the medical professionals is when the resident has diabetes.

Report Continued On LIC9099-C

The department reviewed the Appraisal/Needs Service Plan (Dated: 05/29/2026, 10/21/2024, 09/22/2025) and Medical Assessment (Dated: 03/18/2026,10/15/2025, 9/17/2025) and observed that all residents need some form of assistance with activities of daily living. The department observed all residents in care and observed that they were clean, well groomed, and looked cared for and did not observe any evidence of neglect.

Based on interviews, records reviewed, and observation, there is insufficient evidence to support the allegation that Staff does not ensure resident receives assistance with personal grooming. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #4- Staff do not assist resident with getting dressed.

The details of the complaint allege that facility staff do not assist the resident with getting dressed. On 8/19/2026, from 9:30am-1:00pm, the department interviewed staff (S1-S3), witnesses (W1-W2), and residents’ (R2-R5). The department attempted to interview resident (R1) but could not due to cognitive difficulties. 3 of 3 staff denied the allegation Staff do not assist resident with getting dressed. All staff (S1-S3) stated that they do assist the resident(s) with getting dressed. They state that all residents at the facility needs some form of assistance from staff and they assist all of the residents in the facility.

The department interviewed residents (R2-R5) about the allegation and 4 of 4 residents that were interviewed stated that staff does assist them with getting dressed. The department attempted to interview R1 but could not due to cognitive difficulties. The department interviewed witnesses (W1-W2) about the allegation, and they stated that the staff does assist the resident(s) with getting dressed.

The department reviewed the Appraisal/Needs Service Plan (Dated: 05/29/2026, 10/21/2024, 09/22/2025), Medical Assessment (Dated: 03/18/2026,10/15/2025, 9/17/2025), and Functional Capability Assessment (Dated:05/29/2026, 09/20/2015) and observed that all residents need some form of assistance with activities of daily living. The department observed all residents in care and observed that they were clean, well groomed, and dressed at the time of this investigation and did not observe any evidence of neglect.

Based on interviews, records reviewed, and observation, there is insufficient evidence to support the allegation that Staff do not assist resident with getting dressed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Report Continued On LIC9099-C

The details of the complaint allege that facility staff do not assist the resident with getting out of bed. It was reported that the resident (R1) arms and legs were all curled up because they don’t help her practice ambulation. On 8/19/2026, from 9:30am-1:00pm, the department interviewed staff (S1-S3), witnesses (W1-W2), and residents’ (R2-R5). The department attempted to interview resident (R1) but could not be due to cognitive difficulties. 3 of 3 staff denied the allegation Staff do not assist resident with getting out of bed. All staff (S1-S3) stated that they do assist the resident with getting out of bed. They state that the resident is on hospice and needs assistance with getting out of bed. They state that R1 is not in bed all day and that staff gets them out of bed and assists them with joining the other residents in the living room. S1 stated that resident (R1) has trouble practicing ambulation because of their diagnosis, not because of staff neglect.

The department interviewed residents (R2-R5) about the allegation and 4 of 4 residents that were interviewed stated that staff does assist them with getting out of bed. The department attempted to interview R1 but could not due to cognitive difficulties. The department interviewed witnesses (W1-W2) about the allegation, and they stated that the staff does assist the resident(s) with getting out of bed. However, they state that the resident may be bedridden at this point and can’t participate in ambulation.

The department reviewed the Appraisal/Needs Service Plan (Dated: 05/29/2026, 10/21/2024, 09/22/2025), Medical Assessment (Dated: 03/18/2026,10/15/2025, 9/17/2025), Hospice Care Plan (Dated: 05/16/2026), and Functional Capability Assessment (Dated:05/29/2026, 09/20/2015) and observed that the resident is on hospice and receiving comfort care. The department did not observe any evidence of neglect.

Based on interviews, records reviewed, and observation, there is insufficient evidence to support the allegation that Staff do not assist resident with getting out of bed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #6- Staff are using forms of chemical restraint on resident.

The details of the complaint allege that facility staff are over medicating the resident (R1) to keep them in bed and unaware of what is happening around them. On 8/19/2026, from 9:30am-1:00pm, the department interviewed staff (S1-S3), witnesses (W1-W2), and residents’ (R2-R5). The department attempted to interview resident (R1) but could not due to cognitive difficulties. 3 of 3 staff denied the allegation Staff are using forms of chemical restraint on resident. All staff (S1-S3) stated that they are not using any form of chemical restraint on the resident. Staff stated that the resident is on hospice and is being prescribed medication for pain as a comfort measure for the resident.

The department interviewed residents (R2-R5) about the allegation and 4 of 4 residents that were interviewed stated that they are getting medication as prescribed by their doctor. The department attempted to interview R1 but could not due to cognitive difficulties. The department interviewed witnesses (W1-W2) about the allegation, and they stated that the resident (R1) is in constant pain and is only getting medication as prescribed to lessen the pain the resident is in.

Report Continued On LIC9099-C

Based on interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff are using forms of chemical restraint on resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #7- Staff do not allow resident to make phone calls.

The details of the complaint allege that facility staff are not allowing the resident to make phone calls. It was reported that staff gave the resident a plastic toy phone to use so they think they are making calls to friends. On 8/19/2026, from 9:30am-1:00pm, the department interviewed staff (S1-S3), witnesses (W1-W2), and residents’ (R2-R5). The department attempted to interview resident (R1) but could not due to cognitive difficulties. 3 of 3 staff denied the allegation Staff do not allow resident to make phone calls. All staff (S1-S3) stated that all residents are allowed to use the phone to make phone calls in the facility. They also state that resident (R1) is unable to make phone calls by themselves and don’t have the capacity to use the phone. They state that if someone calls for the resident, they will put phone next to the resident’s ear so that they can hear but they cannot physically make phone calls due to their medical condition.

The department interviewed residents (R2-R5) about the allegation and 4 of 4 residents that were interviewed stated that they are allowed to use the telephone. The department attempted to interview R1 but could not due to cognitive difficulties. The department interviewed witnesses (W1-W2) about the allegation, and they stated that the resident (R1) is incapable of using the telephone and unable to speak due to their medical condition.

The department reviewed the Appraisal/Needs Service Plan (Dated: 05/29/2026, 10/21/2024, 09/22/2025), Medical Assessment (Dated: 03/18/2026,10/15/2025, 9/17/2025), Hospice Care Plan (Dated: 05/16/2026), and Functional Capability Assessment (Dated:05/29/2026, 09/20/2015) and observed that the resident has difficulty using independent functioning skills due to weakness and other medical conditions.

Based on interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff do not allow resident to make phone calls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Report Continued On LIC9099-C

The details of the complaint allege that facility staff do not answer incoming phone calls promptly. It was reported that staff never answer the phone when the public calls. On 8/19/2026, from 9:30am-1:00pm, the department interviewed staff (S1-S3), witnesses (W1-W2), and residents’ (R2-R5). The department attempted to interview resident (R1) but could not due to cognitive difficulties. 3 of 3 staff denied the allegation Staff does not ensure phone calls are answered promptly. All staff (S1-S3) stated that they always answer the phone as quickly as possible. Staff also stated that when they are bathing, changing, and dressing the residents, their first priority is tending to the residents; but the phone calls are answered.

The department interviewed residents (R2-R5) about the allegation and 4 of 4 residents that were interviewed stated that they have noticed that the staff does answer the telephone when someone calls. The department attempted to interview R1 but could not due to cognitive difficulties. The department interviewed witnesses (W1-W2) about the allegation, and they stated that they have noticed that the staff does answer the telephone whenever they visit the facility.

The department observed while at the facility conducting the investigation, the facility received a number of telephone calls, and they were answered promptly.

Based on interviews, and observations, there is insufficient evidence to support the allegation that Staff does not ensure phone calls are answered promptly. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No citations were issued for this complaint investigation.

An exit interview was conducted with Arlene Feliciano, Administrator, and a hard copy of this Complaint Investigation Report was provided.