complaint·July 22, 2025

(Continued from LIC 9099) LPA toured the facility and was permitted entry in Resident #1 (R1's) apartment by Care Staff. LPA conducted six of six staff interviews, three of three witness interviews and interviewed the Executive Director (ED regarding the incident that occurred on Saturday, July 19, 2025. LPA reviewed documents and noted on the Appraisal, Services Plan and Physician's Report that Resident #1 (R1) is independent and only requires assistance with medication. Although R1 does not receive alert charting care for two hour checks, staff continually check on R1; especially if R1 strays from the normal routine. R1 keeps to self and felt the frequent checks were not necessary and wears a bracelet call button. R1 is able to toilet and bathe independently and when staff inquire if R1 needs assistance, R1 does not request assistance. R1 rarely presses the bracelet pendant and was not wearing it at time of fall. On the date of the unwitnessed fall, R1 was found by AM Medical Technician (Med Tech) when entering the apartment to give medications at 8:30am. Responsible Party and Emergency Medical Services (EMS) were immediately called and R1 was transported to a local hospital for evaluation. R1 was admitted to the hospital for further observation. It was reported by AM Med Tech to EMS that R1 received meds at 8pm. ED also observed R1 the day before and did not note anything unusual and observed R1 playing Bingo. PM Med Tech did not notate any changes in condition in charting. Photo documentation was obtained and staff members on-site, at the time of the incident, noted the urine and feces were fresh and that R1 had not been left for an extended period of time. Record review did not show that Resident #1 (R1) has had any falls since admission on April 10, 2025. The incident on July 19, 2025 was the first fall for the resident in the community. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations that: Facility left resident unattended for an extended period of time and Facility did not provide care and supervision resulting in multiple falls are Unsubstantiated. An exit interview was conducted with Executive Director (ED) Cynthia Figueroa and a copy of the report was provided to the facility.