Complaint·October 17, 2025

The investigation revealed the following: Allegation: Staff did not prevent a resident from developing pressure injuries. On 10/16/2025 LPA Watson conducted interviews with Residents #2- Residents #7 (R2-R7). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit.LPA Watson asked the residents if staff neglected to prevent them from developing pressure injuries. Of those interviewed, 6 out of 7 residents denied the above allegation. On 10/16/2025 LPA Watson interviewed Staff #1- Staff #6 (S1-S6). LPA Watson asked the staff if they met the residents’ dietary needs. Of those interviewed, 6 out of 6 staff denied the above allegation. On 10/17/2052, LPA Watson requested documentation and incident reports, from the on duty nurse and staff interviewed, and found that there was no documented evidence of pressure injuries developed by the resident in care. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson 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, therefore the allegation is Unsubstantiated. Allegation: Staff do not ensure that residents' dietary ne eds are met. On 10/16/2025 LPA Watson conducted interviews with Residents #2- Residents #7 (R2-R7). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. LPA Watson asked each resident interviewed if staff did not ensure their dietary needs were met. Of those interviewed, 6 out of 7 residents denied the above allegation. On 10/16/2025 LPA Watson interviewed Staff #1- Staff #6 (S1-S6). LPA Watson asked the staff if they assisted residents with their dietary needs. Of those interviewed, 6 out of 6 staff denied the above allegation. On 10/17/25 LPA Watson requested, obtained and reviewed the weekly menu plan from the facility and it showed that the resident in question was offered three meals a day plus snacks. Based on the information gathered, interviews conducted, and review of records LPA Watson 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, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: Staff do not observe residents for change in conditions. On 10/16/2025 LPA Watson conducted interviews with Residents #2- Residents #7 (R2- R7). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. LPA Watson asked the residents if staff monitored them for any change in conditions. Of those interviewed, 6 out of 7 residents interviewed denied the above allegation. On 10/16/2025 LPA Watson asked the staff if they observed residents for change in conditions. 6 out of 6 staff interviewed denied the above allegation. LPA Watson requested, obtained and reviewed staff log notes and found that there was no documented evidence of changes in conditions about the residents. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson 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, therefore the allegation is Unsubstantiated. Allegation: Staff did not assist residents with grooming. On 10/16/2025 LPA Watson conducted interviews with Residents #2- Residents #7 (R2-R7). LPA Watson asked the residents if staff neglected to assist them with their grooming. An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. Of those interviewed, 6 out of 7 residents denied the above allegation. On 10/16/2025 LPA Watson interviewed Staff #1- Staff #6 (S1-S6). LPA Watson asked the staff if they assisted residents with their grooming needs. Of those interviewed, 6 out of 6 staff denied the above allegation. LPA Watson interviewed 6 staff members and 6 residents and all of those interviewed stated that staff assisted residents with grooming. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson 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, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: Staff do not maintain sanitary facilities. On 10/16/2025 LPA Watson conducted interviews with Residents #2- Residents #7 (R2-R7). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. LPA Watson asked the residents if staff maintained the facility to be sanitary. Of those interviewed, 6 out of 7 denied the above allegation. On 10/16/2025 LPA Watson interviewed Staff #1- Staff #6 (S1-S6). LPA Watson asked the staff if they maintained the facility clean and sanitary. Of those interviewed, 6 out of 6 denied the above allegation. LPA Watson conducted a tour of the facility and found the facility to be clean and in good repair. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson 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, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Marketing / Care Giver Yesenia Robles and a copy of this report was provided.