complaint·February 19, 2026

It was alleged that staff damaged Resident #1 (R1)’s duvet cover after washing it. Interviews with staff, ED, R1, and R1’s responsible parties confirmed that the duvet cover faded in color after it was washed by a staff member. The color faded from bronze to gray. The facility was notified of the damage to the duvet cover on 08/28/2025 and on 09/05/2025, a $207.43 credit was issued by the facility to R1/responsible parties for a replacement duvet cover. Interviews also confirmed that R1 was not left without a blanket and that the facility ensured R1 had appropriate bedding. Based on interview and record review, the allegation “Staff damaged a resident's personal item” is deemed SUBSTANTIATED at this time. However, the LPA determined that there is no direct impact to the residents, presented no danger, and did not effect the overall operation of the facility. This is considered a technical violation and no citations are being issued at this time. Exit interview conducted. A copy of today's report was provided It was alleged that staff did not wake up or dress Resident #1 (R1) on time for their early morning medical appointment on 08/29/2025. LPA conducted interviews with staff and R1’s responsible parties which confirmed that staff were informed in the evening of 08/28/2025 of R1’s appointment, however, proper protocol was not followed. One caregiver was notified in passing in the hallway instead of informing the Resident Care Coordinator or Wellness Office in advance. While the caregiver wrote the appointment details on the office whiteboard, morning shift caregivers were unaware of the appointment. R1’s care plan dated 07/24/2025 documents that R1 “requires Daily STAND BY assist with dressing” twice a day and R1’s assessment signed and dated 04/06/2025 documents that R1 “requires standby assistance with dressing and undressing or assistance with seasonal clothes selection.” Record review reveals that R1 is not on a care or service plan to receive full assistance with waking up or dressing. Interviews with staff and R1 confirmed that R1 prefers to wake up later in the day to afternoon, which is why the morning shift staff had not attempted to dress R1 in the early morning of 08/29/2025. It was not until staff on shift were notified of R1’s medical appointment an hour before the scheduled time, that they were able to assist R1 with waking up and dressing for the appointment. Record review confirms that R1 attended their appointment on 08/29/2025. Facility management held a meeting with R1’s responsible parties and discussed the most appropriate ways to communicate appointments or care-related requests to ensure that all team members get the necessary information needed to act on the requests. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not ensure that resident attended a medical appointment” is deemed UNSUBSTANTIATED at this time. It was further alleged that staff did not ensure R1 received their prescribed nasal spray medication for seventeen (17) days. Staff interviews confirmed that R1 went to a doctor’s appointment for a cough/runny nose on 08/01/2025. The facility received a signed order from a physician on 08/01/2025 for Atrovent 0.06% nasal spray which the facility faxed to Guardian Pharmacy to get filled. The pharmacy stated that it was not a valid order as the refills section and date of birth were blank, and subsequently the pharmacy attempted to contact the prescribing physician. The facility followed up on 08/03/2025, 08/06/2025, and 08/07/2025 and the pharmacy stated the medication was being processed and would soon be delivered. However, the medication was not sent out because the order had expired and R1’s insurance was not allowing for a refill. The medication was received on 08/10/2025 after facility followed up again on 08/09/2025 and 08/10/2025 and the pharmacy was able to contact R1’s insurance to cancel the medication fulfillment at a different pharmacy. Report Continued on LIC9099-C. R1 did not receive the nasal spray for a total of nine (9) days from 08/01/2025-08/10/2025. However, the facility made multiple attempts to receive the medication. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not ensure resident received prescribed medication” is deemed UNSUBSTANTIATED at this time. Lastly, it was alleged that on 08/28/2025, R1 had a confirmed outing to a hair salon with the facility’s transportation but was then left in the heat for 2 and a half hours with no ride back and the facility not answering R1’s/responsible party’s calls. LPA reviewed the employee timecards for 08/28/2025 and observed that both drivers were clocked out of their shifts by 04:33PM. Staff interviews confirmed that the drivers are either scheduled from 8AM-04:30PM or 07:30AM-4PM. LPA interviewed staff who stated that R1 notified them of their appointment shortly before their hair appointment at 2PM on 08/28/2025. R1 and responsible parties were informed that the facility can accommodate the ride to the salon, however, the drivers will be done with their shifts by 04:30PM and that they will not be able to drive R1 back to the facility if the appointment finishes after that time. Around 04:53PM the facility received a call from R1’s responsible party stating that R1 has been waiting in the heat and no one has picked R1 up. The facility ordered a Lyft to R1’s location at 04:56PM with a note to the driver that R1 “is at the hair salon.” The facility attempted to call R1 and R1’s responsible party to inform R1 that the Lyft driver had arrived, but was unable to get a response. The Lyft driver waited at the location until 05:10PM and cancelled the ride due to “rider no-show.” At 05:51PM, the facility ordered another Lyft with the same note to driver, however, the driver cancelled the ride at 06:02PM for “rider no-show.” After the second cancellation, Administrator Lourdes Bustamante drove to R1’s location and picked R1 up. R1 was back at the facility around 06:10PM, approximately 1 hour and 15 minutes from the first Lyft order at 04:56PM. LPA reviewed call logs of the facility’s drivers, R1, and concierge. There were no missed calls observed on 08/28/2025 to either driver. R1’s call logs had no record of calls made to the facility on 08/28/2025, however, there were six (6) missed calls from the facility to R1 between 05:53PM-05:59PM on 08/28/2025. The facility received a call from R1’s responsible party around 04:53PM and the Lyft order was subsequently placed. LPA did not observe missed calls to the concierge. Report Continued on LIC9099-C. The facility ordered multiple Lyft rides and made multiple attempts to contact R1 to arrange the transportation. Regulation states that, “in providing transportation the licensee shall do so directly or make arrangements for this service.” Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not pick resident up from an appointment in a timely manner” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.