complaint·July 17, 2025

(Continued from 9099) Resident #1 (R1) was a resident of the facility’s memory care unit from 3/30/22 to 4/3/22 following discharge from skilled nursing. During R1's stay, they were non-ambulatory and required one to two person assistance with activities of daily living, including transfers, toileting, and mobility due to an unsteady gait when rising from their wheelchair. R1 was incontinent of bowel and bladder and demonstrated cognitive impairment, responding with limited verbal ability. Regarding the allegation, the resident sustained injuries while in care, and staff did not respond to the resident's call light in a timely manner. Records show the facility performed a skin assessment on 4/1/2022, and on 4/2/2022, R1 was assisted to the bathroom by a family member when another fall occurred during transfer. Interviews with staff and the family provided conflicting information regarding the timing and staff response.. Additionally, outside source interviews did not support the claim that staff neglected the residents’ needs. Review of the facility’s call light policy indicates proactive monitoring is encouraged, and there is evidence the team remains alert and responsive. Regarding the allegation, residents are not allowed to go to their rooms during the day. Outside source interviews and staff interviews do not support this allegation. Interviews with staff reveal that residents in the memory care typically leave their personal room door open. Interviews with staff reveal that the facility's policy is to promote resident engagement through group activities designed to encourage socialization and support active participation in the community. These activities generally take place in a large common area within the memory care unit. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Resident Services Director(RSD), Pamela Talamantes . A copy of this report was provided and their signature on this report confirms receipt.