complaint·January 27, 2026

CONTINUE FROM LIC 9099 employee roster, personnel records, admission agreements, MAR, visiting roster for 4/1/24 to 5/1/24, physicians' reports, needs and services plans, level of care notes/factional assessments, special incident reports, hospice binder, and care notes. Allegation: Resident sustained unexplained injuries while in care. Investigation Finding: unsubstantiated. W1 reported that R1 had bruises and scratches from fighting with staff because R1 was refusing medication, W1 also reported that the facility would call W1 and ask if W1 could come and get R1 to take R1s medication and staff informed W1 that the facility wanted to keep R1 medicated due to R1s aggressive behaviors. . S2 further reported that S2 will try 2 or 3 times before charting. S5 reported that S5 has not seen any bruises or scratches on R1 however R1 would hit, and dig R1s nails in staff skin. S5 reported S5 has never witnessed any neglect to R1. S5 reported that the facility has never witnessed R1 with bruises and scratches, S5 stated that S5 worked directly with R1. Therefore, this allegation is UNSUBSTANTIATED. Allegation: Staff are forcing resident to take medication Investigation Finding: unsubstantiated. W1 reported that staff would force R1 to take R1s medication, W1 reported that W1 has never witnessed staff forcing R1 to take R1s medication. W1 further reported that R1 was aggressive and violent and has slapped staff, and threw R1s walker at staff trying to give R1 medication. S2 reported that R1 would often refuse medication and S2 would continue to make rounds and come back and ask R1 again and if R1 would refuse S2 stated that S2 would try a third time and if R1 still refused S2 would chart R1 refused medication. S4 stated that when R1 would refused medication the Medication Technician would prompt R1 2 to 3 times and R1 would sometimes get aggressive and refused and it would be charted. Therefore, this allegation is UNSUBSTANTIATED. Allegation: Staff did not allow resident to have visitors Investigation Finding: unsubstantiated. W1 reported that W1 was not allowed to visit with R1 for two weeks because the facility was lockdown due to COVID. W1 stated that W1 was told all staff and residents had COVID. W1 further reported that R1 was on hospice and W1 was denied visits. CONTINUE ON LIC 9099C2 CONTINUE FROM LIC 9099C W1 reported that W1 informed the Executive Director, and the Executive Director apologized to W1 for W1 not being allowed into the facility to visit. S1 reported that the facility had lockdown orders from the county, but families of hospice residents were allowed to visit their family. S1 further reported that it was brought to S1s attention W1 was at the facility visiting with R1 before R1 passing and W1 and another family member was at the facility while R1 was passing. LPA conducted a record review which showed that W1 had signed into the facility on some days during the period before the period of R1s passing. S5 informed LPA that W1 would sometimes enter the facility in the memory care area, which no one should enter because there is no sign in sheet and that’s the reason some of the days W1 visited the facility was not on the sign in log. Therefore, this allegation is UNSUBSTANTIATED. Allegation: Staff are not able to meet resident's needs Investigation Finding: unsubstantiated. W1 reported that the facility was unable to meet resident needs, alleging that staff could not provide proper care for R1, including administering medications and preventing injuries. S1 stated that the facility was abe to adequately care for R1, noting that the facility was fully staffed and that R1 was receiving hospice services, ensuring continuous care. S2 reported that they attempted to assist R1 with getting out of bed, and when R1 declined, they returned R1 to bed. S2 further stated that R1 was monitored frequently throughout their shift. S3 reported working directly with R1 and indicated that R1 would occasionally refuse assistance with activities of daily living (ADLs). S3 stated that staff continued to check on R1, ensuring the resident was clean, repositioned as needed, and comfortable. S5 confirmed that staff routinely checked on R1 and ensured staff availability whenever care was needed. S2 additionally stated that R1 was on hospice care and received regular visits from hospice nursing staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.