complaint·November 19, 2025

Allegation: Facility staff neglect resulting in residents developing pressure injuries while in care. It is alleged that residents in Memory Care have Stage 3 and 4 decubitus ulcers. It is alleged that residents were left in their bed because they have behaviors. Based on records reviewed, R6’s Hospice flow chart from October 4, 2023, indicated a wound care professional came to the facility to follow up on their wound. R6’s hospice flow sheet from October 4, 2023, to July 23, 2025, does not state that the wound has gotten worse. The report states that either treatment was done or treatment was refused because R6 was aggressive. R6’s facility’s progress notes from November 13, 2024, to February 5, 2025, stated R6 was receiving wound care from their hospice company. There are no notes that indicate the wound was a result of staff neglect nor did the staff note that the condition got worse. R9 was admitted to the facility on August 31, 2019, according to their face sheet dated March 5, 2022. R9 returned to the facility from a skilled nursing facility on January 24, 2025, according to the facility progress notes dated January 24, 2025. Progress notes dated January 26, 2025, staff discovered a right heel wound and coccyx stage 2 wound. R9’s hospice care plan start date for the pressure 2 wound on coccyx was on January 31, 2025. There are no indications on record from the facility progress notes, hospice care plans, and other documents that the facility staff neglect led to pressure injuries for the residents in care. Based on interviews conducted, eight out of eight residents and eight out of eight staff denied allegation that the facility’s staff neglect resulted in residents developing pressure injuries while in care. All staff and residents stated that they have not heard a resident develop pressures due to staff neglect. Based on observations, LPA Kim did not see any form of neglect at the times of visit on February 6,2025, and August 15, 2025. Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all resident interviews and all staff did not corroborate that the pressure injuries occurred to residents due to staff neglect. LPA was able to verify that staff did not neglect residents leading to pressure injuries based on reviewing resident hospice care plans, facility progress notes, and other document records. Continued on LIC9099C Allegation: Food services are inadequate. It is alleged that staff and family often complained of the meals distributed to the memory care residents. Based on interviews conducted, eight out of eight residents and four out of eight staff denied food services are inadequate. Residents stated they liked the food and met their needs. Four out of eight staff stated the food was of good quality, good portion size, and did not have any concerns about the food. Based on the observations of the food service conducted on February 6, 2025, LPA observed lunch was served at 11:00 AM and dinner at 4:30 PM. Residents were served a mixed green salad with dressing, seasoned grilled chicken with brussel sprouts and seasoned potatoes for lunch. On a subsequent visit conducted on August 15, 2025, at 11:15am, LPA observed seasoned chicken, rice, and assorted vegetable medley was served for lunch. LPA observed staff followed all guidelines in distributing fresh and quality for the residents in the memory care dining room as well as the residents receiving food delivered to their unit. Based on record review, LPA reviewed the weekly menus from December 1, 2024, to March 1, 2025, and August 2025. The menus identify 3 healthy meals are given per day. In review of the weekly Food Menu dated February 2, 2025, to February 8, 2025, lists mixed green salad, lemon herb chicken, brussel sprouts, bread/roll, and a choice of beverage for lunch on February 6, 2025. For the lunch menu on August 15, 2025, reads mixed green salad with dressing, honey basil glazed chicken, rice medley, sugar snap peas, fried rice, stir fry vegetable, and a choice of beverage. Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all resident interviews and four out of eight staff did not corroborate that the food was inadequate. LPA was able to verify based on two inspection dates that food served was of quality, portion, and healthy which was also aligned with the weekly menu. Allegation: Licensee is retaining residents with higher level of care needs. It is alleged that the facility moved in residents who need higher level of care. It is alleged the facility moved a resident that needs a higher level of care because they cannot do anything on their own and has a stage 3 wound. It is also alleged that a resident returned from skilled nursing with wounds on their backside. Continued on LIC9099C Based on record review, on February 6, 2025, LPA received a list of all residents with stage 3 pressure injuries provided from ED Morris. R2’s admission agreement was signed and dated January 9, 2025. R2’s Hospice Care Plan dated January 9, 2025, lists pressure ulcer of sacral region unstageable. R2’s physician report dated February 14, 2025, lists that R2 has a right ankle unstageable wound, right ankle/right lateral wound unstageable, and right lateral stage 2 wound. R4’s face sheet dated November 19, 2025, stated resident was admitted to the facility on September 18, 2025. R4’s Hospice Care plan dated February 13, 2024, stated on September 30, 2023, has a stage 3 pressure injury on their right upper buttocks. R9 was admitted to the facility on August 31, 2019, from the facility face sheet dated March 5, 2022. The facility progress notes dated December 27, 2024, R9 diagnosed with UTI Sepsis and was discharged to a Skilled Nursing facility. R9’s returned to the facility on January 24, 2025. On January 26, 2025, Care staff discovered a right heel wound and stage 2 coccyx wound. R9’s Hospice care plan start date for their coccyx pressure 2 injury and right heel were on January 31, 2025. R12’s Hospice care plan dated February 7, 2025, indicated that R12 had a stage 2 ulcer on their right toe since January, 29, 2025, and a stage 3 ulcer on their sacral region since January 29, 2025. All residents are listed have a hospice care plan to take care of their stage 3 or unstageable wounds, thus do not need to have a higher level of care met. Based on interviews conducted, eight out of eight residents and five out of eight staff denied the allegation the facility is retaining residents with higher level of care needs. All residents stated they have not observed or heard other residents needing a higher level of care. Five out of eight staff stated they do not see any resident needing a higher level of care. Based on LPA’s observations, there were no residents that needed a higher level of care at the time of the visits on February 6, 2025, August, 15, 2025, and October 20, 2025. Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all resident interviews and five out of eight staff do not corroborate that the that residents need a higher level of care. LPA was able to verify that the residents didn't need a higher level of care based on reviewing resident hospice care plans, facility progress notes, and face sheets. Continued on LIC9099C Therefore, based on observation, interviews, and records review, LPA did not find sufficient evidence to corroborate the above allegations that Facility staff neglect resulting in residents developing pressure injuries while in care, Food services are inadequate, and Licensee is retaining residents with higher level of care needs 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 conducted and a copy of the report was provided to Resident Services Director Mirian Im