complaint·September 23, 2025

****This report supersedes the complaint investigation report dated 09/23/2025. The purpose of the visit is to add additional information not included in the report; the findings remain the same. ***** Regarding the allegation: Staff are not properly supervising a resident who may be a fall risk. It is alleged staff did not provide adequate supervision, resulting in a resident sustaining multiple hospitalization. It is alleged that R1 has had multiple falls in the facility due to lack of supervision. (8) of (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Interviews with staff showed knowledge of one fall where R1 slipped due to loss of balance related to R1’s medical condition. Staff were present and able to assess R1. 911 was also called and R1 was transported to the hospital. File review shows SIR dated 2/17/25, 3/4/25 (family was present) and 4/6/25 for the fall incident provided to licensing. There were no other recordings of falls R1 may have had in the facility. Staff stated they check on fall risk residents more frequently, every 30 minutes. During activities residents with fall risk are assisted and observed much more frequently. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported 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. Regarding the allegation: Staff were not meeting residents’ personal hygiene needs. It is alleged that the staff is not meeting and providing residents with personal hygiene needs and not assisting residents to change their clothing regularly. (8) of (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. According to staff interviewed, caregivers provide daily assistance services and needs to the residents in memory care (MC). Memory care staff stated they assist the residents with grooming, scheduled showers, a few residents in MC residents required assistance while other residents required full care. Residents who refuse daily living services are reproached at later time in the day. Notes are communicated to next shift staff. LPA Vaid observed MC staff assisting residents with daily living needs. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported 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. CONTINUED ON 9099C.................. ****This report supersedes the complaint investigation report dated 09/23/2025. The purpose of the visit is to add additional information not included in the report; the findings remain the same. ***** Regarding the allegation: Staff are not providing adequate food service to residents. It is alleged that staff are on their phones during mealtimes and not assisting residents with feeding and thus residents have lost a lot of weight since moving to the Memory Care Unit. Eight (8) of eight (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Staff interviewed stated that each resident in the memory care unit has meals prepared according to their dietary orders by the physician. R1's diet plan, and care plan require eating own food and encouragement but not to be fed directly. Staff have stated they however do make sure R1 finishes their meals and will assist if R1 needs it. LPA observed residents eating in the facility on their own, a few residents were observed to be semi-assisted (hand over hand) and fully assisted (residents are fed by staff) by staff. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported 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. Regarding the allegation: Staff did not seek timely medical attention for resident. It is alleged that the staff did not seek timely medical attention for the resident after resident falls. Per complaint, the resident has lost a lot of weight since being at the facility. (8) of (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Staff interviews reveal that R1 care plan was created and finalized in January of 2025. This plan was communicated with R1's responsible party. File review showed last service plan on file for R1 was created on 1/26/24. According to SIR dated 2/17/25, 3/4/25 and 4/6/25 R1 was assessed by the med-techs before going to the hospital, and R1’s family and physician were notified same day. Staff stated R1 had lost weight due to the medications R1 was prescribed, staff communicated observations to family and physician. Medication dose was lowered and administered as prescribed. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported 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. Exit interview was held and copy of this report was provided to Wellness Director Ruth Villa..