complaint·August 5, 2025

Regarding the allegation: Licensee does not ensure enough staff to meet the needs of residents. It is being alleged that the above facility has limited staff and therefore resident #1 (R1)’s needs are not being met. LPA interviewed five (5) staff that confirmed there are five (5) caregivers working the morning shift, afternoon shift and three (3) caregivers on the night shift. In addition, there are four (4) one-on-one staff providing 24 hour care to four (4) residents. LPA interviewed two (2) residents that confirmed their needs are being met by staff. LPA attempted to interview four (4) other residents but they did not understand and/or were able to answer LPA's questions. Let it be noted, these residents are diagnosed with dementia. LPA obtained the caregivers schedules that confirm there are five (5) caregivers in the morning and afternoon shift, three (3) caregivers at night and four (4) staff providing one-on-one care. During LPA's physical tour, LPA observed five (5) caregivers, the Activities Director, two (2) medical technicians, the administrator and assistant administrator and front desk staff. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, n o citation(s ) were issued, and a copy of this report was given to the Administrator. Regarding the allegation: Staff did not seek timely medical attention for resident in care. It is being alleged that because resident #1 (R1) did not receive medical attention on a timely basis, R1 got an infection and needed surgery. During LPA's record review regarding R1, LPA observed the R1 receives ALW-Assisted Living Waiver and is under Tier 4. The assisted living waiver states R1 needs extensive assistance with ADL's-Activities of Daily living. Some of the activities of daily living that R1 needs help with is incontinence care and bathing. ALW documentation shows that R1 needs total dependence of toilet use and bathing. In addition, its shows rashes and itchiness to be a problem. Furthermore, the Appraisal/Needs and Services Plan shows that R1 needs assistance with bladder incontinence; therefore, using pull-ups and/or diapers. R1's Physican's report shows that R1 has a history of skin conditions or breakdown. R1's resident appraisal and Functional Capability Assessment shows R1 needs help with toileting and bathing. LPA interviewed four (4) staff that confirmed R1 needs help with toileting and bathing. One (1) out of the four (4) staff confirmed that R1 had pimples and rashes in their private area and noticed it while showering R1. Another staff confirmed that R1 would always be scratching and noticed rashes in their hand area but also confirmed that they heard other staff saying R1 had rashes in their private area. R1 was taken to the Glendale Memorial Hospital on 07/22/25 by their daughter because of fever and chills and it was determined by medical records that R1 had scrotal cellulitis/scrotal abscess and needed a immediate surgery to avoid sepsis. LPA requested medical records from Glendale Memorial Hospital and they were received on 08/04/25 confirming that R1 needed immediate medical attention. Therefore, based on the LPA's observations of the medical records, ALW documents, physicians report, resident appraisal, functional capabilities and needs and services plan, and staff interviews the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, appeal rights and a copy of this report was given to the Administrator.