Follow-up on corrections·June 26, 2025

On 6/26/2025, Licensing Program Analysts(LPAs) John Calandra, Simi Rai, and Manuel Monter, arrived at the facility to conduct a Case Management visit to cite additional deficiencies discovered during the Department's investigation of a complaint #14-AS-20250417161453 received on 4/17/2025. LPAs were greeted by Fe Arnaiz (ADM1) and William Zach Pilkerton (ADM2), and explained the purpose of the visit. During the visit, LPAs toured the physical plant inside and outside. LPAs reviewed 32 resident files (R1-R32) including Centrally Stored Medication Records, Medication Administration Record (MAR) for January 2025 - March 2025 and centrally stored medications at the facility. Based on the review of R1's Physician's report dated 9/3/2024 which stated R1 has a dual diagnosis of Mental Illness and neurocognitive disorder. Based on review of the facility's plan of operation page 16, "residents determined by their physicians to have a primary diagnosis of mental disorder unrelated to Dementia shall not be accepted or retained." R1 was admitted to the facility on 11/11/2024. On 3/6/2025, Staff S4 was interviewed. Staff S4 stated, he/she conducted a routine check at 4:00am where he/she observed R1 to be in his/her room lying on his/her bed. Based on evidenced reviewed, resident R1 was observed outside of the facility at 1:38am-4:47am. Staff did not observe resident during this time frame. A Type A citation was issued for this violation during today's visit. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. Based on interview of Administrator, Administrator did not have the knowledge to provide appropriate care and supervision to residents. Administrator denied having knowledge that staff are locking resident door for over 12 hours and denied seeing the door secured with a bedsheet. On 5/14/25 ADM 2 was interviewed and admitted he has remote access to facility cameras to redirect staff. However during investigation, ADM2 denied having knowledge of staff's actions at night. A Type A citation was issued for this violation. During today's visit, LPAs requested and received copies of the following documents: All Resident records - Identification Emergency Contact, Appraisal Needs and Services Plan, LIC602A Physicians Report Centrally Stored Medication logs and Medication Administration Records form January- March 2025. LIC 500 Personnel Summary Report During today's visit, 809-D page from 6/24/2025, Case Management was Amended to update the language in the deficiency statement. Changes were discussed with facility representative. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. An exit interview was conducted. This report was reviewed with facility administrator and a copy of the report along with Appeal Rights was provided.