complaint·November 18, 2025

The investigation revealed the following: Regarding: Staff are not maintaining complete and accurate records regarding resident in care. It is alleged that R1 has been asking staff for a copy of resident’s medical records, but staff are only providing records that are incomplete or inaccurate. It is also alleged that medical records are missing due to being misplaced on purpose or because of staff being incompetent. Staff deny the allegation. Interviews with (5) staff indicated that R1 has received copies of medical records the facility has on file, at R1’s request. S1-S3 indicated that copies of R1’s medical records were provided to R1 on 9/23/25 and R1 signed a Release of Medical Information on 9/23/25 and 10/3/25. S1-S3 indicated that the medical records given to R1 were not incomplete or inaccurate and R1’s documents have not been lost or misplaced. S1-S3 further indicated that the medical records the facility has on file are the medical records R1 volunteered to the facility to have on file and other records obtained from the medical services provided at the facility, before R1 changed their doctors. S1-S5 further indicated that due to R1 managing her medical appointments independently, orders and testing results have not been received by the facility from R1’s doctors. Staff stated that they have advised R1 to follow up with their doctors to obtain their medical information and if needed, facility staff can help. Staff stated that R1 has refused to provide them with their doctors’ contact information and therefore, have not been able to provide R1 with assistance in obtaining the medical records R1 is requesting. Interview with R1 indicated that staff did not give them all their medical records and that staff lose them on purpose. However, interviews with (13) out of (15) residents indicated that they have no concerns with how the facility handles their medical records and that medical records released to them are accurate and complete. Record reviews indicated that S1 provided R1 with the requested medical records on 9/24/25 per the Release of Medical Information forms kept on file, signed by S1 and R1. Record reviews also indicated that the facility does not have orders from R1’s doctors requesting labs or other testing. Tour of the med-tech room revealed that resident medical records are centrally stored, kept locked and inaccessible to unauthorized individuals. Based on interviews, record review and observations, the allegation that staff are not maintaining complete and accurate resident records could not be corroborated. ***Report continues on LIC 9099-C page 2 Regarding: Staff are not adhering to resident's Admissions Agreement. It is alleged that staff are supposed to check resident’s blood pressure daily after dizzy spells per resident’s Admissions Agreement, but staff are not doing so. Staff deny the allegation. Interviews with (5) staff revealed that R1 does not have a physician’s order in place to have their blood pressure checked daily. Staff indicated that blood pressure checks are conducted on residents who have physician’s orders in place or when emergencies services are called for residents who may be experiencing medical emergencies to have the vials information on hand to be provided to medics. S1 further indicated that the facility’s parameters for medical aid do not include taking vital signs from residents without a physician’s order in place. S3-S6 also indicated that they have advised R1 to provide the facility with any orders from their doctor if there has been changes to their health; however, R1 has not done so. Interviews with (14) out of (15) residents indicated that staff meet their medical needs according to their doctor’s orders and have no concerns at this time. Interview with R1 indicated that staff are not checking their blood pressure after their dizzy spells as indicated by their Admissions Agreement; however, review of R1’s Admissions Agreement does not indicate that the facility must conduct blood pressure checks on R1. Further record review indicated that R1 does not have an order from their physician on file for blood pressure checks. Based on interviews and record reviews, the allegation that staff are not adhering to resident’s Admissions Agreement could not be corroborated. Regarding: Staff are not meeting resident's needs. It is alleged that per resident’s Admissions Agreement, staff are supposed to check on resident every 4-6 hours because they are a fall risk, but they are not. Staff deny the allegation. Interviews with (10) out of (10) staff revealed that staff would not wait 4-6 hours to check on residents because checks are conducted every (2) hours or sooner. Staff indicated that all residents who live at the facility, whether they are independent or require a higher level of care, are checked on by staff every (2) hours or as needed in between scheduled checks. Staff further indicated that residents who are at risk of falling get checked on every (1) to (2) hours during scheduled rounds. Interviews with (14) out of (15) residents revealed that staff are conducting visits every (1) to (2) hours by caregivers and additional visits are conducted during medication passes by med-tech staff. Residents further indicated that they have no concerns about how staff are conducting their checks during their rounds. ***Report continues on LIC 9099-C page 3 R1 stated during interview that staff do not follow their Admissions Agreement, which R1 says that the agreement indicates that staff must check on them every 4-6 hours. However, review of R1’s Admissions Agreement does not indicate that the facility should be checking on resident every 4-6 hours. Based on interviews and record review, the allegation that staff are not meeting resident’s needs could not be corroborated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated . An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.