complaint·January 30, 2026

Cont. from LIC 9099 It was alleged that the resident #1 (R1) fell out of bed the day he was admitted to the facility. Staff revealed that fall risk residents are identified during initial assessment. Based on initial assessment, if the resident is a fall risk, they draft specific plan of action with preventive measures. R1 was fully independent and not a fall risk resident. Although R1 was not a fall risk, they requested assistance two (2) times. First time for fall incident and second time after injuring themselves in the bathroom. For both incidents R1 was assisted by the staff and no medical attention was required. Residents interviewed during this investigation did not address any concerns regarding their assistance. A review of R1’s facility file revealed that R1 was admitted as an independent resident. R1 was not identified as a fall risk and did not require frequent checks or specific supervision to prevent falls. No information or evidence was available to support the allegation. Therefore, based on interviews, and record review, the allegation is unsubstantiated at this time. Staff are not answering resident call buttons in a timely manner. It was alleged that R1 pushed the button on their neck alert and no one came to his room. R1 called family members to call the Facility so that they could pick him up. The Staff call 911 to lift R1. Staff interviewed during this visit revealed that when residents push their pendant usually, they try to respond as soon as possible. Sometime residents not only push call buttons, but also either call front desk or their responsible party may call front desk. Average time to respond is between 7 to 10 min. Staff #1 (S1) and staff #2 (S2) stated that R1 used their pendant 2 times and both times they responded within 5-7 minutes. The information provided during investigation does not support the allegation. Therefore, based on interviews, observation, and record review, the allegation is unsubstantiated at this time. Staff are not meeting residents’ bathing needs. It was alleged that on June 26, 2025, when R1 was getting ready for the doctor’s appointment, R1 smelled as if they hadn’t been bathed/showered in days. Staff indicated that they have shower schedule and they are following shower shceduel. Staff were unable to recall providing shower assistance to the R1. Other residents interviewed during this visit did not address any concerns regarding their bathing assistance. A review of R1’s record verifies that R1 did not require bathing assistance. The information provided during investigation does not support the allegation. Therefore, based on interviews and record review, the allegation is unsubstantiated at this time. Cont. on LIC 9099-C Cont. LIC 9099-C Staff are not properly notifying responsible parties of residents change in condition Staff did not seek timely medical attention for resident in care It was reported that R1’s foot was scratched and inflamed, and shown signs of infection and the facility did not report R1’s responsible party. R1 had inflammation on their foot and facility did not seek medical attention. R1 was sent to ER when they visited the doctor for routine appointment. Staff interviewed during investigation were unable to recall seeing R1’s foot swollen. They stated R1 was able to ambulate and never complained about their foot or legs getting swollen. S1 and S2 verified that there were 2 instances when they assisted R1 and both times R1 was assisted by the caregivers and med techs and did not articulate any pain or discomfort. R1 insisted that he does not require medical care. A review of R1’s file revealed that a resident did not have a health condition requiring specific follow up or medical assistance/care. R1’s health condition was not changed during their stay in the facility. Records verified the information provided by staff. Other residents interviewed during investigation did not reveal any information regarding their medical care or timely medical assistance. Based on interviews and record review, there is not enough information and/or evidence to verify the allegations. Therefore, the allegations are deemed unsubstantiated at this time. Staff did not adequately ensure residents’ room was clean and orderly Staff did not ensure residents laundry was washed Staff were not properly addressing pests in the facility It was reported that R1 room often had rotting food, trash was piled, laundry was not being washed, and there were bugs all over R1’s bed, clothes, and in the linen closet." During facility inspection LPA did not observe any food, piled trash or dirty laundry in residents’ rooms. Staff revealed that residents’ rooms are checked every day. The trash is picked up every morning and as needed. R1 was always ordering food in his room. They would take the tray there and after an hour they would go and pick up the food. No staff had seen rotten food or bugs all over R1’s room including closets. Staff also revealed that R1 was getting laundry service as per request. When R1 wanted their clothes to be washed or bed to be changed, they informed staff to come and pick up the laundry. Other residents interviewed during this visit had no issues regarding housekeeping or laundry services. The information available during this visit does not verify the allegations. Therefore, based on inspection, observation, interviews and record review, the allegations are unsubstantiated at this time. Exit interview conducted. Copy of this report was provided.