complaint·July 31, 2025

Allegation: Staff are not ensuring resident exercises . It is alleged that resident (R1's) was ordered by a physician to participate in daily exercise after recent medical issue, but on Friday, July 25, 2025 the resident was not observed in the 10:30 AM exercise class. An interview with R1 was attempted, but due to cognitive impairment they were not able to give feedback pertaining to the allegation. A total of 12 residents were interviewed. They confirmed exercise class is offered daily in the morning. A total of nine (9) staff were interviewed. Staff interviews revealed that resident (R1) is supposed to attend daily exercise classes at 10:30 AM, but sometimes the resident does not attend because staff are not escorting the resident to the exercise activity room. Staff stated that the resident is usually a late riser and eats breakfast close to 9:30 AM. During today's visit, LPA observed the exercise class begin at 10:30 AM. At 10:43 AM, resident (R1) was observed sitting by themselves in the dining room table. There was no food in front of the resident. Dining staff stated the resident was done with their meal at 10:15 AM. Resident (R1's) home health agency was contacted. The agency director said that the resident was discharged from physical therapy services on July 10, 2025. Home health representative stated that 2 facility staff were notified that R1 should join daily activities and group exercises, and should be encouraged to walk daily with supervision and use of walker. There is sufficient evidence to support the allegation. Based on interviews, observation, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Virginia Garcia. A copy of the report and appeal rights were provided. Allegation: Staff are not meeting residents showering needs. The complaint alleges resident (R1) is supposed to get three showers per week but it in recent weeks it was observed that the resident's hair was dirty, not combed, and their body wash had not been used. A total of nine (9) staff were interviewed. All staff said that residents are showered three times a week. Review of shower assignment indicates R1 is showered Monday, Wednesday, and Fridays. According to staff, R1's responsible party recently requested the resident be showered four times per week, and in recent weeks the resident has been showered on Sundays as well. A total of 12 residents were interviewed. The majority of residents have cognitive impairment. One (1) resident stated they are not showered. Resident (R1) was not oriented to time and place. The resident was well groomed and was last showered yesterday. Observation of residents, record review, and interviews conducted did not support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to Virginia Garcia.