complaint·November 21, 2025

(Continued from LIC9099) It was alleged lack of Neglect/Lack of supervision resulted in resident's daily needs not being met. More specifically, it was alleged that a memory care resident was being allowed to sleep, eat, and eliminate on the floor without appropriate staff intervention. Interviews and records review confirmed that the resident has a cultural preference for sleeping on the floor, which the facility has attempted to accommodate through environmental adjustments and redirection. While occasional incidents of urination were acknowledged, staff reported that these are promptly addressed. No evidence was found to support claims of defecation or neglect. It was further alleged that Staff threw water at resident's face. More specifically, that a staff member threw water in a resident’s face following a request for water. The incident was reportedly linked to a behavioral episode involving law enforcement. Staff interviews revealed no witnesses to the alleged act, and the resident was observed to have access to water at the time of the visit; however, the water container was full and sitting on the dresser. The resident has a diagnosis of dementia with behavioral and perceptual challenges, and no corroborating evidence was found. It was further alleged Staff did not ensure resident's podiatry care needs were met. More specifically, Concerns were raised regarding residents’ access to podiatry services. The investigation identified two residents with podiatry related issues. Records showed that one resident is enrolled in an external care program and has a documented history of refusing services, while the other has a pattern of non-compliance with care routines. Staff interviews confirmed that podiatry services are regularly offered, and facility observations revealed posted notices advertising mobile podiatry access. No evidence was found indicating systemic neglect or failure to provide access to care. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator/Assistant Executive Director Lane Hermosillo t o whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.