complaint·April 15, 2026

Allegation: Staff did not adequately assist resident with care needs in a timely manner. It was alleged that Resident #1 (R1), who uses a walker and requires assistance with ambulation and restroom use, experienced delays in staff response times when requesting assistance. It was further alleged that due to delayed responses, R1 attempted to ambulate independently and nearly fainted in the restroom on an unknown date. To investigate this allegation, LPA conducted interviews with the Administrator and Staff #1 (S1). Both denied the allegation. The Administrator stated that R1 always received assistance shortly after requesting help and that staffing levels were sufficient to meet resident needs. Staff reported that residents are monitored and assisted as needed. LPA interviewed R1 on 02/04/2025, who reported concerns regarding delays in staff responding to requests for assistance and described an incident on an unknown date in which R1 nearly fainted while using the restroom. During the visit on 02/04/2025, LPA observed staff present and providing care and supervision to all residents including R1. Based on LPA’s observation during the initial and subsequent visits, staff were available to assist residents and respond to care needs. Based on interviews conducted and LPA’s observation during the visit, there was insufficient evidence to support the claim that staff did not adequately assist R1 with care needs in a timely manner. Therefore, the allegation is Unsubstantiated . The finding is based on information gathered during the investigation regarding conditions and practices during the time R1 resided at the facility. At the time the investigation concluded, R1 was no longer residing at the facility. Allegation: Staff did not respect resident’s choices regarding their care needs. It was alleged that staff did not respect R1’s expressed care preferences. Specifically, it was alleged that an unknown individual provided a shower to R1 without proper identification and performed an unsolicited massage despite R1 verbally objecting. To investigate this allegation, LPA interviewed the Administrator and S1, both of whom denied the allegation. The Administrator stated that showers are provided by a designated shower aide and that the facility does not provide massages to residents. Although the Administrator was initially unable to identify the individual who provided the shower at the time of questioning, documentation obtained during the course of the investigation clarified that R1 was enrolled in hospice services with Glendale Hospice Inc beginning 01/24/2025. Records reviewed indicate that R1 received two hospice visits dated 01/28/2025 and 01/31/2025. During both visits, hospice staff provided shower assistance using a shower chair and applied lotion to R1’s skin as part of routine personal care. Documentation further reflects that R1 was discharged from hospice services on 01/31/2025 at the request of R1’s Power of Attorney (POA), who revoked hospice benefits and service Continue on LIC 9099C Based on documentation reviewed and interviews conducted, the personal care services in question were provided by hospice agency staff, a third-party provider, and not by facility staff. While R1 expressed dissatisfaction with the services received, there is insufficient evidence to support that facility staff failed to respect R1’s care preferences. Therefore, the allegation is Unsubstantiated. Allegation: Staff did not provide the resident with adequate food service. It was alleged that staff failed to provide Resident 1 (R1) with adequate and appropriate meals, including meals consistent with R1’s dietary needs. Additionally, it was reported that R1 was repeatedly served cold sandwiches and inappropriate meals. To investigate this allegation, the Licensing Program Analyst (LPA) interviewed the Administrator, who denied the claim and stated that meals are freshly prepared. The Administrator further indicated that R1 was provided with a special low-sodium diet in accordance with their dietary requirements. Facility staff also denied the allegation, reporting that residents, including R1, are served a variety of meals, including hot meals, and are offered substitutions when necessary. On 02/04/2025, the LPA interviewed R1, who expressed dissatisfaction with the meals and stated that cold sandwiches were served on several occasions. R1 also reported that staff encouraged them to eat the meals provided when alternatives were refused. During the initial visit on 02/04/2025, LPA observed lunch service. Residents were served a toasted sandwich, a bowl of soup, salad, juice, and water. Additionally, interviews with two (2) other residents revealed no concerns regarding food service. Based on the LPA’s observations and interviews conducted, residents were observed to be receiving adequate meals consistent with their dietary needs. Therefore, there is insufficient evidence to support the allegation that staff failed to provide R1 with adequate food service or meals consistent with dietary requirements. Therefore, the allegation is deemed Unsubstantiated at this time. This finding is based on information gathered during the investigation regarding conditions and practices while R1 resided at the facility. At the time the investigation was concluded, R1 was no longer residing at the facility. Continue on LIC 9099C Allegation: Staff spoke to resident in an inappropriate manner. It was alleged that staff spoke to R1 in an inappropriate and disrespectful manner, including yelling and making demeaning statements. To investigate this allegation, LPA interviewed the Administrator and S1, both of whom denied speaking inappropriately to R1 and stated residents are treated respectfully. During initial visit on 02/04/2025, LPA interviewed R1, who reported being yelled at when requesting assistance and when asking questions regarding showers and meals. R1 reported being told, “Eat it or starve.” During the initial visit, LPA did not observe any staff speaking inappropriately to R1 or any other residents in care. Moreover, LPA observed that all residents are treated with respect and dignity. Additionally, on 02/04/2025, LPA conducted interview with three (3) out of four (4) residents of which two (2) residents did not express any concern regarding the allegation and informed LPA that they are being spoken to appropriately. Therefore, based on interviews and observation this allegation is Unsubstantiated at this time. The finding is based on conditions and practices observed during the period R1 resided at the facility. At the time of the investigation conclusion, R1 was no longer residing at the facility. Appeal rights explained. Exit interview conducted and copy of this report signed and provided. Allegation: Staff interfered with resident’s visit. It was alleged that staff interfered with R1’s authorized healthcare visits. Specifically, it was alleged that a Home Health Nurse sent by R1’s physician and authorized by R1’s Power of Attorney (POA) was prevented from assessing R1. To investigate this allegation, LPA interviewed the Administrator, who denied interfering with visits and stated R1 was already receiving hospice services at the time. Additionally, LPA interviewed the Home Health Nurse, who stated that on 01/31/2025 she was prevented from completing an assessment by a hospice nurse who stated R1 was already enrolled in hospice services and that hospice was responsible for care. The nurse left the facility without completing the assessment. LPA confirmed through interviews that hospice enrollment occurred without documented POA consent. Based on the interviews and corroborating information, the allegation is Substantiated. The finding is based on conditions and practices observed during the period R1 resided at the facility. At the time of the investigation conclusion, R1 was no longer residing at the facility. Allegation: Staff confined resident to their room. It was alleged that staff confined R1 to their room and restricted their access to common areas, allowing them to leave only for meals. To investigate this allegation, LPA interviewed the Administrator, who denied restricting residents and stated residents may use common areas freely. Staff reported that residents are allowed in the living room and participate in activities. During initial visit on 02/04/2025, LPA interviewed R1, who reported being told they had to remain in their room and could only come out for meals. During the initial visit on 02/04/2025, LPA observed residents spending the majority of the day in their rooms, no activities being offered, and residents being directed back to their rooms immediately after meals. Based on interviews and observation, the allegation is Substantiated. The finding is based on conditions and practices observed during the period R1 resided at the facility. At the time of the investigation conclusion, R1 was no longer residing at the facility. Continue on LIC 9099C Allegation: Staff did not provide resident or their authorized representative with requested information in a timely manner. It was alleged that staff failed to provide R1 and their authorized representative (POA) with requested information regarding care providers and medical decisions. To investigate this allegation, LPA interviewed the Administrator, who stated attempts were made to contact the POA regarding hospice enrollment. LPA reviewed the Administrator’s outgoing call logs and did not observe any calls placed to the POA. Furthermore, LPA interviewed the POA and placement representatives, who stated they were not informed of hospice enrollment and were not provided with information regarding individuals brought into the facility to care for R1. Based on interviews and record review, the allegation is Substantiated. The finding is based on conditions and practices observed during the period R1 resided at the facility. At the time of the investigation conclusion, R1 was no longer residing at the facility. Allegation: Staff intimidated resident into signing paperwork. It was alleged that staff intimidated R1 into signing paperwork by using threats or coercive behavior. To investigate this allegation, LPA interviewed the Administrator, who denied forcing or intimidating R1 and stated paperwork was explained prior to signing. Facility staff denied witnessing coercion. During the initial visit on 02/04/2025, LPA interviewed R1, who reported that the Administrator and an unknown male pressured them to sign paperwork, stating they had to sign “or else.” R1 reported the male became angry and that they feared physical harm. LPA observed R1 display fear and emotional distress while recounting the incident. The facility was unable to provide documentation demonstrating informed consent or POA involvement. Based on interviews and observation, the allegation is Substantiated. The finding is based on conditions and practices observed during the period R1 resided at the facility. At the time of the investigation conclusion, R1 was no longer residing at the facility. Deficiencies issued and appeal rights explained. Exit interview conducted and copy of this report signed and provided.