Complaint·August 6, 2025

The investigation revealed the following: Regarding the allegation “Staff do not respond to residents' calls for assistance in a timely manner,” it is alleged that staff is taking a long time to respond to a resident’s call light request. On 07/24/25, between 12:10 PM and 1:45 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff denied the allegation. 5 out of 6 staff stated that they respond to a residents call light request within 5 minutes. On 07/24/25, between 1:55 PM and 3:30 PM, LPA conducted interviews with R1-R3, and on 07/25/25 between 1:30 PM and 2:45 PM, LPA conducted interviews with R4-R7 and attempted to interview R8-R9. Of those interviewed, 6 out of 7 residents said staff responds to their call light request in a timely manner. 7 out of 7 residents stated that there is enough staff to meet their needs. On 08/06/25, LPA Gonzalez reviewed the Personnel Roster (Dated: 07/01/2025) and observed that there is sufficient staff to meet the needs of the residents. Additionally, on 08/06/25, LPA Gonzalez inspected resident bedrooms #208 and #319 and observed call buttons to be in operable condition. ¬LPA Gonzalez observed Assistant Administrator, Jesus Chavez pull the call light cord and found that the facility staff responded in less than four minutes. Based on record review, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Regarding the allegation “Staff do not ensure residents’ incontinence needs are being met,” it is alleged that residents are left in soiled briefs for extended periods of time. On 07/24/25, between 12:10 PM and 1:45 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff stated that no residents is left in the same briefs for 24 hours or longer. 5 out of 6 staff stated that residents briefs are changed every 2 hours. Continued on LIC9099-C On 07/24/25, between 1:55 PM and 3:30 PM, LPA conducted interviews with R1-R3, and on 07/25/25 between 1:30 PM and 2:45 PM, LPA conducted interviews with R4-R8 and attempted to interview R8-R9. Of those interviewed, 5 out of 7 residents stated that they have not been left in soiled briefs for an extended period of time, and 2 out of 7 residents stated that they don’t require toileting assistance. 5 out of 7 residents stated that staff has not left a resident in the same briefs for 24 hours or longer, and 2 out of 7 residents stated that they didn’t know if a resident has been left in the same briefs for 24 hours or longer. Based on record review, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Regarding the allegation, “Staff do not ensure residents' showering needs are being met,” it is alleged that there are several residents who haven’t been showered in a month or longer. On 07/24/25, between 12:10 PM and 1:45 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff stated that resident’s bathing needs are being met. S2 stated that the residents get two showers a week and the days vary depending on their schedule, hospice residents get one from staff and two from the hospice agency, and that they just check on their independent residents and make sure they are showering and ask them if they need assistance. S1 stated that if a resident refuses, staff will attempt three times and then document it on their skin monitoring form. The staff will sign that form after 3 attempts and so will the resident. On 07/24/25, between 1:55 PM and 3:30 PM, LPA conducted interviews with R1-R3, and on 07/25/25 between 1:30 PM and 2:45 PM, LPA conducted interviews with R4-R7 and attempted to interview R8-R9. Of those interviewed, 4 out of 7 residents said their bathing needs are being met, and 3 out 7 residents said they don’t require any bathing assistance. 4 out of 7 residents stated they get at least 2 showers a week, and 3 out of 7 residents said they don’t require any bathing assistance. 4 out of 7 residents said no resident has gone 24 hours or more without bathing, and 3 out of 7 residents said they didn’t know if a resident has gone 24 hours or more without bathing. 6 out of 7 residents said they are satisfied with the services provided to them. On 08/05/25 LPA conducted a review of the shower schedule and observed documentation indicating showers are done twice a week, LPA also observed documented refusals from residents on the facility’s skin monitoring forms. Based on record review, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Regarding the allegation, “Staff do not ensure facility remains free of bad odors,” it is alleged that a resident’s room has a very bad odor. On 07/24/25, between 12:10 PM and 1:45 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 5 out of 6 staff stated that a resident messes with their catheter and it causes urine to spill and get on the floor. 6 out of 6 staff said that housekeeping deep cleans resident’s room once a week, and as needed. 4 out of 6 staff denied that a resident’s room has a bad odor, and 2 out 6 staff said it does have a bad odor. On 07/24/25, between 1:55 PM and 3:30 PM, LPA conducted interviews with R1-R3, and on 07/25/25 between 1:30 PM and 2:45 PM, LPA conducted interviews with R4-R7 and attempted to interview R8-R9. Of those interviewed, 1 resident stated they have had accidents with their catheter which caused urine to spill on the floor, and that staff does a very good job at keeping their room clean. 6 out of 7 residents said they don’t know if a resident’s room has bad odor. 7 out of 7 residents stated that housekeeping cleans their room at least once a week. Based on record review, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Continued on LIC9099-C Regarding the allegation, “Staff are mismanaging residents' medication,” it is alleged that residents are missing their medications due to staff not ordering refills timely. On 07/24/25, between 12:10 PM and 1:45 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 4 out of 6 staff denied the allegation, and 2 out of 6 staff said they did not know if residents are missing their medications due to staff not ordering refills timely. 5 out of 6 staff said that staff administers the resident’s medication on time and as prescribed, and 1 out of 6 staff said they did not know if staff administers the resident’s medication on time and as prescribed. S2 stated that a resident has asked staff for their PRN medication, but sometimes they are out of it. often. S2 stated that it’s an issue because that certain medication is controlled, and requires for the resident to be seen by their doctor before they prescribe a refill. S2 stated that staff will call the doctor a week before the medication runs out, but the doctor won’t come until a week later to see the resident, which will cause a delay in the resident receiving the medication. On 07/24/25, between 1:55 PM and 3:30 PM, LPA conducted interviews with R1-R3, and on 07/25/25 between 1:30 PM and 2:45 PM, LPA conducted interviews with R4-R7 and attempted to interview R8-R9. Of those interviewed, 7 out 7 residents said they receive their medications on time and as prescribed by their physician. 7 out of 7 residents said they have not missed any medication due to the medication not being available. LPA Gonzalez conducted a record review of the MARs for the months of June and July 2025 for R1-R3 and R8 and did not observe any discrepancies or mismanaging of residents’ medication. Based on observation, interviews conducted, and a review of records, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted with Assistant Administrator, Jesus Chavez, and a copy of this report and appeal rights was provided.