Complaint·April 27, 2026

It was learned that R1 eventually was diagnosed with dementia and was moved over to the memory care portion, Traditions, of this facility at a later date. This diagnosis was reflected on the LIC 602 that was completed on 02/20/2024. Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that this resident, R1, had already lost their dentures from a prior incident that took place earlier in their placement to this facility. It was learned that there was a second incident that took place where the resident was unable to recall where their dentures were last seen and their family and responsible party were made responsible in replacing them again. Based on interviews conducted during the course of this investigation, it was learned that the staff were tasked with making sure that proper oral hygiene and care were to be maintained on a daily basis for R1. This task was outlined and implemented on the daily tasks assignment for R1. After the completion of each assigned task, facility personnel would then initial to note that the task had been completed. It was learned that facility staff were unaware as to how the dentures for R1 would have gone missing and did not have a plausible reason at this time. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interview Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that the new pain medication, Hydrocodone, was prescribed and filled on 11/09/2025 when it was dropped off to this facility. This medication was only a PRN and was not to be dispensed on a daily basis but only when the resident, R1, expressed pain and discomfort. It was learned that from 11/09/2025 to when the resident got their staples removed from their back surgery on 11/19/2025, this medication was dispensed a total of 11 times to the resident. Each time this medication was dispensed it was noted and entered into the facility Medication Administration Record (MAR) and charting notes as well. Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that there were daily tasks assigned to the facility staff which were to be performed and completed relevant to the care and supervision of R1 on a daily basis. These tasks ranged from toileting, dressing, and assistance with Activities of Daily Living (ADLs). It was observed that these tasks were completed and signed off after their completion by the staff person on duty. These duties spanned over 24 hours for each day and were broken down for each 8 hour shift as well. It was observed that the tasks were clearly signed off by the assigned facility personnel without any missing initials at this time. The months that were reviewed were from the beginning of August 2025 until the end of November 2025. Based on interviews conducted during the course of this investigation, it was learned that the Memory Care Director had oversight for the daily tasks assigned to the facility personnel and audited these logs on a weekly to a monthly basis to make sure that they were complete and not missing any duties at any given time. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interview