complaint·August 13, 2025

Allegation: “Questionable Death”, it is being alleged that Resident 1 (R1) passed away in the TV (activity) room without anyone noticing. Interviews conducted with S4, S5, and S11 (were witnesses to the incident) revealed the following: 3 out of 3 staff denied the allegation. Interviews conducted with W10 and W11 revealed the following: 2 out of 2 witnesses denied the allegation. Interviews conducted with R14 to R19 (were witnesses to the incident) revealed the following: 2 out of 6 residents denied the allegation. 4 out of 6 resident interviews were inconclusive. R1’s records revealed the following: R1’s Service Assessment Form dated 01/14/2025 indicated that R1 required full assistance in daily living. R1’s Unusual Incident Report and Death Report dated 07/12/2025 indicated that R1 was declining in health; R1 was seen earlier that day by Home Health around 9:30 AM; R1 was in the activity room and checked around 11:10 AM; R1 was in the dining room and checked around 12:09 PM and paramedics were called due to R1 being unresponsive; paramedics came to the facility and pronounced R1’s death. Based on the department’s interviews and records reviewed this allegation is unfounded. Unfounded: This agency has investigated the complaint alleging "Questionable Death." We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. No deficiencies were provided. An exit interview was conducted, and a copy of this report was left with the Administrator, Heather Argueta and Resident Care Coordinator, Corina Kahl. Investigation revealed the following: Allegation: “Licensee does not ensure facility has enough staff to meet the needs of the residents who require two person assist”, it is being alleged that when using Hoyer lifts only one staff member uses the equipment instead of two staff members. Interviews conducted with R2 to R13 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Interviews conducted with W1 to W9 revealed the following: 9 out of 9 witnesses denied the allegation. Observations on 08/04/2025 revealed the following: two staff members were observed using a Hoyer lift. Based on the department’s interviews and observations this allegation is unsubstantiated. 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: “Staff are not properly assisting residents who are a fall risk.” Interviews conducted with R2 to R13 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Interviews conducted with W1 to W9 revealed the following: 9 out of 9 witnesses denied the allegation. Records reviewed of In-Service Training dated 07/15/2025 revealed the following: staff were trained on Policy: Fall Occurrence Checklist. Records reviewed of Resident Service Assessment Form revealed the following: there are two sections in the form that address fall risk; one section is named Safety and the other Mobility, both sections state if resident has had a history of falls and the prevention measures that are being implemented. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. 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: “Staff yell at residents.” Interviews conducted with R2 to R13 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Interviews conducted with W1 to W9 revealed the following: 8 out of 9 witnesses denied the allegation. 1 out of 9 witnesses agreed with the allegation. Observations on 08/04/2025, 08/06/2025, 08/07/2025, and 08/13/2025 revealed the following: staff were not observed yelling at residents. Based on the department’s interviews and observations, and this allegation is unsubstantiated. 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: “Staff do not offer engaging activities for residents.” Interviews conducted with R2 to R13 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Interviews conducted with W1 to W9 revealed the following: 9 out of 9 witnesses denied the allegation. Observations on 08/04/2025, 08/06/2025, and 08/13/2025 revealed the following: the facility follows their activity schedule; activities are from Monday to Sunday and start from 9:30 AM to 4:00 PM; activities vary from fitness, music, personal care, bingo, movie & popcorn, market trips, religious studies, cooking classes, etc. Records reviewed of Resident Service Assessment Form revealed the following: there is a section for Activities and Resident Preferences are noted. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. 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: “Staff are not meeting residents bathing needs.” Interviews conducted with R2 to R13 revealed the following: 11 out of 12 residents denied the allegation. 1 out of 12 residents were unable to answer questions. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Interviews conducted with W1 to W9 revealed the following: 8 out of 9 witnesses denied the allegation. 1 out of 9 witnesses agreed with the allegation. Observations on 08/04/2025, 08/06/2025, 08/07/2025, and 08/13/2025 revealed the following: residents were observed clean and well groomed. Records reviewed of Resident Service Assessment Form revealed the following: there is a section for Bathing, and it states if residents are independent, require assistance, and how often residents would like to be bathed. Record reviewed of Shower Books for August 2025 revealed the following: the facility has a shower schedule for each floor; the shower schedule is from Monday to Sunday; the time is divided from morning, evening, and nocturnal time. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. 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 deficiencies were provided. An exit interview was conducted, and a copy of this report was left with the Administrator, Heather Argueta and Resident Care Coordinator, Corina Kahl.