complaint·January 30, 2026

Regarding allegations: Staff did not supervise the resident according to their needs and Resident sustained unexplained scratches their back. It was alleged that staff allowed the resident to wander without supervision and scratch themself, resident sustained unexplained scratches to their back. The Administrator and staff were interviewed and denied the allegation. They stated that residents are supervised at all times based on individual needs and that adequate supervision is consistently provided. Staff reported that R1 required full hands-on assistance with all activities of daily living, including meal setup with guidance and reminders, as well as incontinent care. Staff further stated that R1 had a history of sensitive skin with intermittent skin issues. According to staff, lotions and ointments prescribed by R1’s physician were applied daily per doctor’s orders, even when skin irritation was not present. Staff stated they did not observe any new scratches or marks on R1’s skin prior to R1 moving out of the facility. The LPA reviewed R1’s file and confirmed that skin treatments were administered in accordance with the physician’s orders. Records indicated that on the day R1 was picked up by the responsible party, R1’s skin was clear, intact, and free of lesions / scratches. . The LPA interviewed eight residents. One resident was unable to respond due to cognitive impairment. The remaining seven residents denied the allegation and reported that staff are available and provide assistance according to residents’ needs. No concerns regarding supervision or staffing were reported. While LPA walked around to conduct resident interviews, LPA observed sufficient staff on duty and actively assisting residents. Review of the staff roster, daily staffing logs, caregiver schedules, and daily assignment sheets indicated that the facility maintained sufficient staffing to meet resident needs. Based on staff and resident interviews, observations, and record review, the allegation that staff failed to supervise R1 resulting in unexplained scratches was not corroborated. Regarding allegation: Staff did not administer medication as prescribed. It was alleged that staff was not applying ointments to R1 as prescribed. The Administrator and staff were interviewed and denied the allegation. They stated that all medications and ointments are administered and applied to residents in accordance with physicians’ orders and within required time frames. Staff reported that R1 had sensitive skin and that all prescribed creams and ointments were applied as ordered . Staff further stated that the facility purchased and provided sensitive-skin body wash to assist during periods when R1 experienced skin irritation flare-ups that caused itching. Continue 9099C The LPA reviewed R1’s file and medical records and observed documentation indicating that all prescribed creams and ointments were applied as ordered by the physician and within the prescribed time frames. The LPA interviewed eight residents. One resident was unable to respond due to cognitive impairment. The remaining seven residents denied the allegation and stated they had no concerns regarding the administration of their medications. Based on staff interviews, resident interviews, and record review, the allegation that staff failed to administer medication and apply prescribed ointments to R1 was not corroborated. Regarding allegations: Staff left the resident soiled and Staff allowed the resident to be malodorous. It was alleged that staff left the resident soiled and malodorous. The Administrator and staff were interviewed and denied the allegation. They stated that adequate staffing and supervision are maintained at all times and that residents are supervised according to their individual needs. Staff reported that R1 required full hands-on assistance with all activities of daily living, including meal setup with guidance and reminders, as well as incontinent care. Administrator and staff stated that R1 and other residents were never left soiled or malodorous. Staff reported that R1’s incontinence care was managed every shift and that R1 was checked at least every two hours, and more frequently as needed. Staff further stated that R1 was a wanderer and required frequent safety checks, encouragement to rest, and reminders to drink fluids. Staff indicated they did not observe R1 or other residents to be malodorous. The LPA interviewed eight residents, four of whom required incontinence care. Four residents stated that staff check on them frequently and change them as needed. Interviewed residents stated that they didn't noticed that residents are malodorous. One resident was unable to respond due to cognitive impairment. While LPA walked around to conduct resident interviews, LPA observed sufficient staff on duty assisting residents and did not observe any residents to be malodorous. Based on staff interviews, resident interviews, and LPA observations, the allegation that staff left R1 soiled and malodorous was not corroborated. Continue 9099C Regarding allegation: Facility did not provide a refund. It was alleged that the facility failed to issue a refund following R1’s move out. The final notice of intent to move R1 was received from R1’s responsible party. The Administrator and staff reported that the facility received an email from R1’s responsible party on 09/08/25 stating that R1 would be moving to another facility, with a discharge date of 09/10/25. The LPA reviewed email correspondence between R1’s responsible party and the facility administration, which confirmed that notification of the move was sent on 09/08/25 and that R1 was scheduled to move out on 09/10/25. Facility administration informed the responsible party that the email would be accepted as the required 30-day written notice, in accordance with the admission agreement. The LPA reviewed the Admission Agreement, specifically the Termination and Refund Policy, which states: “You may terminate this Agreement at any time, with or without cause, by giving the Administrator of the Community or his/her designee thirty (30) days prior written notice of termination. You need not cite a specific reason for termination.” Based on Admission Agreement R1's responsible party should pay the rent until 10/08/25 but since R1's belongings move on 09/10/25, facility Administration waived charges from 10/01/25 to 10/08/25 and refund was issued. The LPA requested and reviewed the monthly invoice for R1 and observed that R1 paid the full rent amount for September 2025 and on the invoice indicated that a refund for 20 days in the mount of September was issued to the responsible party. The LPA obtained a copies of invoice and the Check #6128 in the amount of $9,686.67. Check was cashed. Based on record review and documentation obtained, the facility issued a refund in accordance with the Admission Agreement. The allegation that the facility failed to provide a refund was not corroborated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and a report was provided to Selene Rangel-Gutierez