complaint·May 8, 2025

Based on interviews, observations, and a review of documentation, there is insufficient evidence to support the allegation that residents were not changed in a timely manner due to staffing shortages. Therefore, the allegation is Unsubstantiated at this time. Allegation # 2: It was alleged that, due to a lack of staff, residents were not receiving timely assistance. To investigate this allegation, (LPA) conducted interviews and reviewed facility and resident records, as well as other relevant documentation, on the following dates: July 23, 2023; February 29, 2024; December 3, 2024; February 6, 2025; April 24, 2025; and May 8, 2025, between 9:45 a.m. and 3:30 p.m. It was specifically alleged that Resident #1 (R1) was found hanging off the side of the bed without their oxygen mask, and due to staffing issues, R1 did not receive timely assistance, resulting in low oxygen levels. It was also alleged that staff were not aware that R1 had returned to the facility following a hospital discharge. However, it was reported to LPA that the area where R1 resides is secured and requires staff to input an emergency key code to open the door, indicating that staff were aware of R1’s return to the facility. Additionally,interviews revealed that R1 was known to frequently touch their face or move around in bed, which often caused the oxygen mask to become displaced. Staff were aware of this behavior and reported performing routine checks to ensure the mask was properly positioned. Although some concerns regarding staffing were mentioned during interviews, LPA observed adequate staffing levels during each visit. Based on interviews, observations, and a review of facility records, there is insufficient evidence to support the allegation that residents, including R1, were not receiving timely assistance due to staffing shortages. Therefore, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided. Citation issued, civil penalty assessed, appeal rights, and copy of report provided. Plan of correction is cleared, due to facility recent medication training conducted by credential training from the Allen Flores Group on April 8 and 9, 2025. Exit interview conducted.