complaint·April 16, 2026

Pg 2 On the allegation Questionable death the following was found: On 03/14/2025, R1 received assistance from S1 at 0410 hours. At 0610 hours, R1 pressed their pendant. S1 responded within three minutes and eight seconds. R1 was found in their apartment after an unwitnessed fall. S1 promptly called 911. This was R1’s only fall while living at the facility. It was reported by R1 that they tripped getting out of bed to go to the bathroom and struck their head on a piece of furniture. The department received a certified copy of R1’s death certificate on 4/11/2025 that stated that R1 died on 03/15/2025 and the cause of death was listed as an intracranial hemorrhage, pathological fall, and paroxysmal atrial fibrillation. Interviews with Senior general Manager revealed that the facility advised R1s family in February 2025 that they believed R1 should be moved to memory care however this recommendation was declined. Therefore, the allegation Questionable death is Unsubstantiated. On the allegation Staff are not meeting the needs of the residents the following was found: On 6/25/2025 R2- R4 were interviewed. R2 stated that their experience at the facility has been “wonderful.” and added that the facility staff are the “nicest” people they have ever been in contact with. R2 states that they are checked on four to five times a day and that facility staff are “in and out of the room constantly.” R2 states that if they need the facility staff’s assistance, they can pull the cord in the bathroom or press the pendant that they wear around their neck. R2 states that they once “accidentally” pressed their pendant, and the facility staff responded within “five minutes.” R3 and R4 also had similar positive experiences at the facility. LPA also observed that the facility had up to date needs and service plans for requested residents and were aware of their needs. Therefore, the allegation Staff are not meeting the needs of the residents is Unsubstantiated. Report continues on LIC9099-C Pg 3 On the allegation Staff do not have planned activities for the residents the following was found: During the course of the investigation the LPA made multiple visits to the facility. On all occasions LPA observed residents engaged in activities being led by care partners and or Activities directors in the common area. LPA also observed activities calendars posted in common areas throughout all subsequent visits. LPA interviewed R5 and R7 who both mentioned activities such as Bingo and Blackjack. LPA observed that the activities available were of variety and crafted to meet the needs of residents therefore the allegation Staff do not have planned activities for the residents is Unsubstantiated. On the allegation Staff are not meeting the residents hygiene needs the following was found: LPA conducted interviews, reviewed files, and made observations. R2-R4 where interviewed as well as R5 and R7. All residents interviewed expressed that their needs are being met at the facility. LPA observed that residents hygiene appeared good and observed residents with clean clothes, hair, and bodies. LPA was unable to identify a resident whose hygiene needs were not being met Therefore the allegation Staff are not meeting the residents hygiene needs is Unsubstantiated. Report continues on LIC9099-C Pg 4 On the allegation Staff is not present for a significant amount of time the following was found: During the course of the investigation the LPA made multiple visits to the facility. LPA conducted interviews, reviewed files, and made observations. LPA observed adequate staffing during all visits. LPA also interviewed R5 who stated that, “staff check on them during shift changes but not periodically during the day unless they push their button. States that they will check if there is out of the ordinary behavior like not coming down for bingo.” R7 states that, “staff come and checks on them around shift changes. States that they do not want staff to check on them anymore than they already do.” A review of staff schedules showed that staff is sufficient and present. Therefore the allegation Staff is not present for a significant amount of time is Unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.