The investigation into the allegation, staff did not ensure resident's diapering needs were being met resulting in resident developing multiple UTI's, revealed the following. R1 moved into the facility on May 8, 2025 and moved out of the facility on May 29, 2026. R1 was on hospice. Staff 1 and Staff 2 reported that during their stay at the facility R1 never had home health visits and never went to the hospital. A review of facility records and hospice records shows there is no mention of any Urinary Tract Infections (UTI) for R1. LPA attempted to contact Hospice Nurse 1 but did not receive a response. Staff 1 and Staff 2 reported that R1 never had a UTI. LPA attempted to contact Witness 1 (W1) who was reported to have knowledge of the incident, but they did not respond to requests for an interview. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff does not provide adequate supervision to residents, revealed the following. It was reported that Staff 1 and Staff 2 leave the facility for extended periods of time and leave the residents unsupervised or have their minor child watch residents. No dates or times were provided as to when this happened. Staff 1 and Staff 2 denied the allegation. 2 out of 4 residents reported they have never been left unattended. 2 out of 4 residents could not be interviewed and did not respond to the LPA’s questions. LPA attempted to contact 2 responsible parties of residents 1 and 2 but never received a response. During the initial visit and the visit on September 15, 2026, LPA did not observe anyone at the facility except the residents and Staff 1 and Staff 2. None of the evidence gathered supports the allegation. Based on the evidence gathered, the allegation is deemed unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff smokes marijuana during shift, revealed the following. It was reported that Staff 1 told Witness 1 that they smoke marijuana at night and offered marijuana to Witness 1. LPA interviewed Staff 2 who reported they have never seen anyone smoke anything at the facility. Staff 1 denied the allegation. LPA interviewed 2 out of 4 residents who reported that they have never seen anyone smoke and have never smelled marijuana or cigarette smoke at the facility. Witness 1 did not respond to requests for an interview.

The investigation into the allegation, staff did not ensure resident's nutrition needs were being met, revealed the following. It was reported that during Resident 1’s (R1) last few days at the facility they were not provided with their pureed meals. Staff 1 and Staff 2 denied the report and stated that R1 was always provided with their pureed meals but R1 did not always finish their meals because their appetite had declined. LPA attempted to contact Witness 1 (W1) who was reported to have knowledge of the incident, but they did not respond to requests for an interview. R1 passed away on June 19, 2026, and was not interviewed. LPA interviewed 2 out of 4 residents who reported they were unaware if R1 ate pureed meals or not. LPA attempted to contact Hospice Nurse 1 but never received a response. Based on the evidence gathered, the allegation is deemed unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff did not provide a comfortable environment for resident, revealed the following. It was reported that facility staff did not provide a comfortable environment because facility staff made inappropriate comments to residents and their visitors which resulted in visitors and residents feeling uncomfortable. No specific details were provided as to what was said by facility staff. LPA interviewed 2 out of 4 residents who reported they had no issues with facility staff and felt comfortable living at the facility. 2 out of 2 facility staff denied the allegation and reported they never did anything inappropriate at the facility. LPA attempted to contact 2 responsible parties of residents 1 and 2 but never received a response. LPA attempted to contact Witness 1 (W1) who was reported to have knowledge of the incident but they did not respond to requests for an interview. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff is operating beyond the scope of license, revealed the following, it was reported that staff at the facility had converted the garage into 3 bedrooms and the new bedrooms were intended for resident use. LPA toured the facility on June 3, 2026, and on September 15, 2026. The garage has not been converted into 3 bedrooms.

An exit interview was conducted and a copy of the report provided.