complaint·February 23, 2026

LPA observed that R1's Hydroxyzine Pam 50 MG medication was prescribed on January 29, 2026. LPA observed that R1's Systane Balance 0.6% eye drops were prescribed on December 12, 2025. LPA reviewed R1's medication orders as of February 23, 2026, which confirmed both medications still had active orders. Two staff present during the visit confirmed the facility did not have R1's prescribed Hydroxyzine Pam 50 MG medication or his Systane Balance 0.6% eye drops physically present, or available to R1 if they were needed. Additionally, LPA observed the facility did not have discontinue orders on file for these two as needed medications for R1, and therefore, these medications should be available at the facility. LPA attempted to conduct an interview with R1, however, R1 was unable to be qualified for an interview. LPA attempted to conduct an additional five resident interviews. However, none of the residents were able to be qualified for an interview. Regarding the allegation, staff does not provide adequate supervision resulting in resident sustaining multiple falls, the following has been concluded: It was alleged that staff does not provide adequate supervision resulting in R1 sustaining multiple falls. LPA reviewed R1's records. LPA observed that R1 was admitted to the facility on December 12, 2025. LPA reviewed R1's resident assessment dated November 15, 2025, which states that R1 is a fall concern. LPA reviewed R1's patient visit summary dated February 13, 2026, which stated that R1 has a history of repeated falls, and is an increased risk for falls due to confusion, muscle weakness, and immobility. LPA observed that R1 has sustained four documented falls while at the facility, including on February 8, February 10, and twice on February 12, 2026. LPA observed that the fall R1 sustained on February 8, 2026, required R1 to be sent out to the hospital due to multiple skin lacerations, as well as R1 refusing first aid treatment from staff. LPA observed the three other falls did not require R1 to be sent to the hospital, however, R1 sustained skin tears as a result of the falls. LPA conducted four staff interviews. Four out of the four staff interviewed confirmed R1 has sustained multiple falls while at the facility. LPA observed that there are no re-assessments on file for R1, despite having four documented fall at the facility, to determine if there was a change in condition or if more supervision is necessary. Furthermore, there are no documented fall prevention techniques in place despite R1 having four documents falls at the facility between February 8, and February 12, 2026. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D. An exit interview was conducted with Director of Wellness Alex Gutierrez. A copy of the report and Appeal Rights were provided.