complaint·September 26, 2025

Resident 1 was later transferred to a skilled nursing facility for short-term rehabilitation before returning to the facility with Home Health services. Although Resident 1 did sustain an injury, evidence shows facility staff responded appropriately by seeking medical treatment and monitoring his condition. There is insufficient evidence to prove neglect or lack of supervision directly caused the fall or injury. Based on interviews conducted and records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. Regarding the allegation facility did not perform a reappraisal to confirm resident needed a higher level of care. On 03/31/2024, Facility Administrators observed Resident 1’s change in condition and immediately arranged for his return to the hospital, informing staff he could not return to the facility unless independent. Resident 1 was placed at skilled nursing for physical therapy and later cleared by a physician to return to the facility with Home Health support. The facility Administrator identified Resident 1’s increased care needs, initiated transfer to a higher level of care, and coordinated follow-up. Upon re-evaluation, Resident 1 was determined to again meet the criteria for independent living with Home Health assistance. Based on interviews conducted and records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. No deficiencies cited Per title 22 regulations. Exit interview was conducted with facility Administrator Rebecca Rayo. A copy of this report along with appeal rights were provided.