complaint·September 30, 2025

[CONTINUED FROM LIC 9099] The Complainant claimed that R1 and R2 each lost significant body weight during the approximate three (3) months that these residents lived at the facility, and that facility staff either claimed the residents refused to eat or did not wake the residents up to eat. However, according to regulations, assistance with eating does involve forcing a resident to eat/drink when they are not in the mood. When R1 moved into the facility in mid-December 2020, their admitting diagnosis was “senile degeneration of the brain.” R1’s hospice nursing assessment said they displayed “clinical evidence of advancing illness” and an “inability to maintain sufficient fluid and caloric intake,” with R1 typically eating only “50-75% of meals.” Over the successive months, visiting hospice nurses noted R1 was generally unhappy about living at a facility (instead of their own home), was sometimes agitated, was increasingly lethargic, and declined many meals offered to them by facility staff. By 03/08/2021, a hospice nurse wrote R1’s nutrition was “very poor” and that R1 “rarely [ate] more than 1/3 of any food offered.” R1 moved out to another care facility on 03/15/2021; yet even in this new setting, R1’s appetite did not improve. When R2 moved into the facility in mid-December 2020, R2’s terminal diagnosis was “cerebral infarction [aka “stroke”] due to embolism of unspecified cerebral artery.” Their hospice nursing assessment at that time showed R2 was oriented only to themselves, showed fluctuating level of consciousness with periods of “significant lethargy,” was “forgetful and confused,” and their baseline oral intake was “sips and bites.” It also showed R2 “rarely [ate] a complete meal,” that they “generally [ate] only about 1/2 of any food offered,” that they had “inability to maintain hydration and caloric intake,” and that “dysphagia prevents [R2] from receiving enough food/fluid.” Successive hospice visit notes showed R2’s eating skill showed some improvement starting 12/29/2020, but R2’s appetite was still inconsistent; some days R2 refused to eat and spat out their medicines. R2 moved out to another care facility on 03/15/2021; yet even in this new setting, R2’s appetite did not significantly improve. The Complainant said there was a dramatic decline in R1 and R2’s respective level of alertness and physical functioning during their time living at the facility. However, the Complainant later conceded that they believed facility staff gave R1 and R2 their medications according to how they were prescribed. Hospice care records for R1 or R2 did not suggest a pattern of facility staff deviating from the physician’s medication orders. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Per hospice records, R2 did have a rash in their peri area that was observed during their first week at the facility, but R2 had also recently arrived to the facility following a long inpatient stay at a hospital. Nystatin powder was applied to the rash, which successfully resolved the issue. The rash did not return for the remainder of R2’s residency at the facility. The Complainant told LPA they first observed R2’s teeth being “dirty” on 03/21/2021, but this date was also nearly a week after R2 had moved out of Sunview Gardens 2 (to their next care facility). Per hospice records, that agency’s Home Health Aide consistently visited the facility twice per week to bathe R1 and R2; there was no pattern of missed bed baths detectable to CCLD. LPA was unable to interview R1 and R2 for this case, due to both residents having passed away by the date CCLD received the complaint. However, LPA interviewed multiple outside sources and 2 of 2 manager and 10 of 11 caregivers who worked at the facility during the complaint timeframe. (One caregiver had since left employment and could not be reached for interview). The interviews did not support violations relating to the allegations; on the contrary, they tended to show staff provided necessary assistance to R1 and R2 with regard to eating/feeding, correct medications, and personal hygiene. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not assist resident(s) with eating, that Licensee did not give medications as prescribed, or that Licensee did not meet resident’s hygiene needs. These three (3) allegations are therefore Unsubstantiated, and no deficiencies were cited for them. An exit interview was conducted with Lead Caregiver Michelle Rodriguez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. An electronic set of these same documents was E-mailed to Licensee/Administrator Felicity Arcangeli.