complaint·December 17, 2025

Regarding the allegation: Staff did not reappraise resident for a change in condition. It was alleged that staff failed to conduct a proper reassessment for Resident 1 (R1). To investigate the allegation, LPA conducted interviews with two (2) staff members. LPA’s interview with S2 revealed that residents are reappraised every six (6) months, or first 30 days upon their move-in date or if there is a change of condition noted. During LPA’s record review, LPA observed R1’s latest re-appraisal (listed as Functional Evaluation for this investigation) to have been done on 6/16/2025. R1’s Admission date was documented as 6/06/2025. When questioned as to why R1’s re-appraisal documented them to have “Short term/memory impairment” with “…occasional confusion and some difficulty in recalling, “details”, S2 stated that although R1 has not been diagnosed with any cognitive impairments, they have been observed to have some forgetfulness. LPA’s review of R1’s Pre-placement Appraisal dated 5/30/2025 confirmed R1’s mental condition was documented as Mild Cognitive Impairment (MCI) which collaborated with their current Functional Evaluation. LPA’s review of R1’s Physician Report dated 5/30/2025, R1’s diagnosis were documented as various medical conditions but no indication of MCI’s notated nor discussed. R1’s Physician's Report documented them as followed but not limited to: Lack of Hazard Awareness- No Lack of Impulse Control- No Unsafe Wandering- No Sundowning Behavior- No Elopement- No Additional, record review of R1’s Unusual Incident Reports (SIRs) dated 11/26/2025 and 12/9/2025 documented R1 to have had unwitnessed falls near their bedside where they sustained injuries requiring them to be sent to the hospital. LPA’s record review of R1’s current Functional Evaluation report documented R1’s fall Risk to have, “non slip shoes when transferring/ambulating…”. However, due to R1’s falls, S2 stated that they ordered a fall mat to be placed by R1’s bedside and a high-back wheelchair. LPA confirmed the orders dates of 12/11/2025 and 12/15/2025 of said items. During LPA’s physical plant tour, LPA observed R1’s bedroom to be neat, clean and organized. LPA observed R1’s fall mat next to their bed and their high-back wheelchair. LPA observed R1 to be asleep. LPA observed no obstructions or tripping hazards in R1’s bedroom. (Continue to LIC 9099-C) Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the temporary Executive Director.