Complaint·February 5, 2025

- Incident for Resident_1 (R1) on 7/20/24—reported on 8/2/24 - Incident for R2 on 7/22/24—reported on 8/2/24 - Incident for R3 on 7/22/24—reported on 8/2/24 - Incident for R4 on 7/22/24—reported on 8/2/24 - Incident for R5 on 8/26/24—reported on 9/4/24 - Incident for R6 on 9/2/24—reported on 9/10/24 - Incident for R7 on 10/22/24—reported on 10/30/24 - Incident for R8 on 10/6/24—reported on 10/16/24 - Incident for R9 on 10/7/24—reported on 10/16/24 - Incident for R7 on 10/17/24—reported on 10/25/24 - Incident for R10 on 11/4/24—reported on 11/12/24 - Incident for R11 on 11/12/24—reported on 11/20/24 - Incident for R12 on 1/5/25—reported on 1/13/25 Interview with the Director of Health and Wellness (DHW), Ashley Melendez, indicated that reportable incidents include hospitalizations, injuries, and death, and that the Administrator, Alyssa Sellers (AD), determines which incidents require reporting. However, the process of incident reporting, as explained by the staff, involves multiple steps of review and approval. For example, reports are written by the DHW, reviewed by the AD and sometimes forwarded to corporate for additional review before being submitted to the Department. Interview with AD confirmed that those are not assessed as non-serious incidents, are not reported to the licensing agency. These are documented internally but not submitted as written reports to the licensing agency unless the incident is deemed significant by clinical staff. Based on the information gathered, the allegation that the facility does not report incidents to the Department in a timely manner is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Note that failure to correct deficiencies may result in civil penalties. Exit interview was conducted with Alyssa Sellers, AD and Laura Willingham, COO and a copy of this report and appeal rights were provided.