complaint·March 20, 2026

Interview with ED reported that R1 was identified as a fall risk and staff were made aware to provide increased and sufficient supervision. ED noted R1 began to have a cognitive and communication decline, contributing to the falls. Interview with Staff 1 (S1) reported R1 had a care plan that included the use of a Geriatric Chair and bed railings to help prevent falls. Interview with R1’s responsible party confirmed facility staff communicated fall incidents and when R1 was transported to the hospital in a timely manner. A review of medical hospital records obtained did not reference injuries resulting from falls. Additionally, a review of incident reports submitted to Community Care Licensing identified four fall-related incidents involving R1. Facility staff appropriately documented responses, such as arranging medical transport and notifying responsible parties and hospice agencies. Regarding the allegation of lack of supervision/neglect resulting in Resident 1 (R1) developing a wound with an infection, it was alleged that R1 was not receiving adequate wound care which caused the condition of the wound to worsen. Interview with AW1 indicated that R1 appeared to have a severe infection and AW1 was unsure how often wound care was being provided. AW1 stated that their observations of R1’s condition, were the result of inadequate care by staff. Interview with S1 revealed that R1 was on hospice and experiencing a decline in health. S1 reported that R1 had a diagnosis of cognitive impairment and a form of cancer that resulted in a wound on R1’s left hand. S1 emphasized that a body check completed during admission on February 26, 2026, documented a skin tear and a bump on R1’s left hand. A review of R1’s medical records confirmed a cancerous growth on the left hand. Additionally, the growth was described as an open wound; however, it was noted on the medical record to be non-infected and did not develop while R1 was in care at the facility. Interview with Resident 2 (R2) indicated that staff attended to R1 daily and R2 observed the bandage on R1’s left arm changed regularly. Interview with Responsible Party (RP), reported visiting R1 a couple times a week and reported staff provided good care for R1. RP emphasized they had no concerns neglect or abuse had occurred at the facility. A police report dated June 24, 2025 was obtained and revealed a case related to the allegations regarding neglect and abuse of R1 at the facility was investigated and closed with no evidence of suspected abuse or neglect by facility staff. Regarding the allegation that staff do not maintain residents’ hygiene, it was reported that on June 18, 2025, R1 was observed to have a foul odor, with maggots and flies on R1's left arm. An interview with Additional Witness 1 (AW1) indicated they were visiting R2 when they noticed a foul odor coming from R1. AW1 stated that upon approaching R1, they observed a maggot on R1’s left arm. Interview with ED reported that they had not seen or been made aware of maggots on R1. ED denied the allegation and noted a bathing log was maintained by hospice and staff would assist with cleaning the bandage in between hospice visits. Interview with AW2 reported that staff often attended to R1 and maintained the cleanliness of R1’s room. It was also denied that AW2 observed maggots on R1. Interview with 5 of 5 staff corroborated denying observing maggots on R1. Interview with R1’s Responsible Party reported they had no concerns regarding R1’s care and observed R1’s room to be clean and organized during visits. A review of June and July 2025 hospice records revealed R1 was bathed on 6/5, 6/10, 6/12, 6/17, 6/19, 6/24, 6/26, 7/1, 7/3, 7/8, 7/15 and 7/17. Additionally, documentation showed that multiple wound care visits had been completed. Based on interviews, record reviews, and observations, the allegations of lack of supervision and neglect resulting in R1 sustaining injuries and a wound infection, and staff do not maintain resident’s hygiene has been deemed UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia.