Complaint·October 31, 2025

Face sheets for (5) residents. The facility’s personnel report and resident roster. Investigation revealed the following: Regarding the allegation "Residents sustained unexplained injuries": It was alleged that residents were observed with injuries for physical abuse. Interviews conducted with (5) staff and (5) residents revealed that none of the residents denied sustaining injuries; however, all injuries discussed were explained and attributed to known causes. Staff confirmed that any injuries were addressed appropriately. LPA observations during multiple visits revealed that no residents were observed with visible injuries at the time of inspection. Record reviews—including incident reports, care plans, observation logs, and hospital summaries—showed that all injuries were documented with corresponding explanations and follow-up. On 10/11/2025, LPA requested physician notes and hospital records. Additionally, LPA was informed and documented internally by administrator—that one resident refused medical attention. The resident’s Power of Attorney (POA) was notified and agreed with the decision to decline treatment. Documentation also confirmed that family members or responsible parties were notified in a timely manner. Additionally, LPA reviewed documentation and spoke directly with family members of residents involved. Family members confirmed being informed of the incidents and were aware of the care provided. On 10/11/2025, LPA requested physician notes and hospital records. LPA was informed—and it was documented internally—that one resident refused medical attention. The resident’s Power of Attorney (POA) was notified and agreed with the decision to decline treatment. Based on the evidence gathered, 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. Regarding the allegation "Staff did not prevent resident from injuring another resident": It was alleged that staff failed to intervene in an incident where one resident injured another. LPA observations revealed no indication of staff shortages or lack of supervision during the visits. Record reviews revealed that although one resident has verbally directed inappropriate or insulting language toward other residents and staff, the behavior is well-documented internally. Records show that the resident’s family has been notified, hourly safety checks are conducted, medical adjustments have been made, and all three shifts of caregivers assist with ADLs, redirect the resident, and help de-escalate behaviors as needed. Interviews with residents and staff revealed that no resident had injured another. Please see report continuation on LIC9099-C In fact, one resident shared that staff actively prevent such incidents by locking the elevator to certain floors at specific times of the day to limit unsupervised movement and reduce the risk of resident-to-resident contact. Based on the evidence gathered, 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 cited during this visit. An exit interview was conducted with the Medical Technician Danna Romero , and a copy of this report, along with the Appeal Rights, was provided.