Complaint·February 11, 2026

On October 2, 2025, LPA Steve Chang interviewed resident R1. Residents R1 was unable to provide an answer to questions posed and did not provide any relevant information due to neurocognitive disorder. On December 26, 2026, LPA Monter interviewed Staff S1. S1 stated R1 would try to hit the care staff when they are providing care. S1 stated they can in as a group, 4, to change R1. S1 stated he/she was the first to pull R1 up. S1 stated his/her intent in pulling was to get R1 up, so they can change R1. S1 reiterated he/she approached this way due to the fact that R1 can be combative and they need to change R1 quickly. S1 acknowledged that he/she pulled R1 with too much force. S1 stated he/she had to pull because R1 is very strong and resistive to care and heavy. S1 stated the other issue was staff S2 had also pulled when he/she pulled, causing to much momentum. S1 stated this caused R1 to be pulled forward too much and resulted in R1 falling. S1 stated since R1 was already on the floor, R1 still needed to be changed on the floor. S1 stated while R1 was on the floor, he/she was just holding his/her hands because R1 was being resistive and combative with the staff. S1 stated that day was the first time they changed R1 on the floor. On January 6 and 16, 2026, LPA Monter interviewed staff S2 and S4. S2 stated when staff attempt to change resident R1: R1 will swing his/her arms and kick in response. S2 stated regarding the incident that occurred on September 26, 2025, they were assisting R1 with changing. S2 stated there were 3 staff assisting in changing R1. S2 stated they tried their best to change R1. S2 stated they tried to position R1 to the middle of the bed but R1 was pushing and hitting. S2 stated this resulted in R1 falling. S2 stated staff tried to prevent the fall, but R1 was still being combative. S2 stated since R1 was now on the ground, the other staff were helping R1 get changed. S2 stated it was difficult as R1 was still being combative, he/she and S1 were holding R1’s arms to prevent being hit by R1. S2 stated they don’t change R1 on the floor. Staff S4 stated regarding the incident that occurred on September 26, 2025, he/she was shadowing a care giver and was informed they would change R1. S4 stated based on what he/she was taught, the way they changed R1 was how he/she was shown by the other care givers. S4 stated he/she was only doing what he/she was taught. S4 stated R1 was being combative. S4 stated the days he/she was shadowing, he/she observed R1 being combative every time he/she was being changed. S4 stated he/she doesn’t remember the details of that day. S4 stated he/she doesn’t know what to say. S4 stated he/she only did as instructed. S4 stated he/she was sorry for what happened. On February 11, 2026, LPA reviewed video footage dated September 25, 2025 with Administrator Camille Burke . (This video footage has staff S2, S4 and S14 present.) ADM stated the video footage showed the staff members in question where clearly only goal oriented. ADM stated the method they used to get R1 up and changed was the incorrect way of changing a resident who is being combative. On February 11, 2026, LPA reviewed video footage dated September 26, 2025 with Administrator Camille Burke . (This video has staff S1-S4 present) ADM stated the video footage showed a similar situation where multiple staff members where using incorrect methods to change a combative resident, and using to much force to pull the resident up from their bed. Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. A deficiency is being cited during todays visit. See LIC9099-D. This report was reviewed with Administrator Camille Burke. Appeal Rights were provided. On December 15, 2025, LPA Manuel Monter interviewed Witness W1. W1 stated on August 17, 2025, R2 was not provided his/her morning medications. W1 stated he/she used to have video footage showing R2 was not assisted that morning with his/her medications, but did not save the video footage. On December 17, 2025, LPA Manuel Monter interviewed staff S5-S10. 6 Out of 6 staff (S5-S10) stated they are not aware of any instance where a resident was not administered their medication. On December 17, 2025, LPA Manuel Monter interviewed residents R1, R3-R5. LPA attempted to interview R1, but R1 would digress to unrelated topics. R1 was unable to provide any relevant information due to neurocognitive disorder. R3 stated he/she gets his/her medication on time with no issues. 2 Out of 4 (R4 & R5) stated they handle their own medications and do not need staff assistance. On December 17, 2025, LPA Manuel Monter interview Administrator (ADM) April Trixia. ADM stated she isn’t aware of an instance where a resident was not administered their medication. On December 26, 2025 LPA Manuel Monter interviewed residents R6-R14. Resident 8 Out of 9 residents (R6-R13) stated they have been receiving their medications on time and hasn’t had any issues regarding their medications. Resident R14 was unable to provide an answer to questions posed and did not provide any relevant information due to neurocognitive disorder. On December 26, 2025, LPA Manuel Monter interviewed staff S1. S1 stated he/she does not handle residents medications and is not aware of any issues regarding residents medications. On January 6 and 7, 2026, LPA Manuel Monter interviewed S2, S4, S11-S13. S2 stated he/she has found medication tablets on the ground in residents bedrooms. S2 stated when he/she brought this to the attention of the Medtech’s, the Medtech’s would say it wasn’t them and had occurred on the previous shift. S2 stated he/she couldn’t specify which bedrooms or how many instances he/she has found medications on residents beds / bedroom floor. Staff S4 and S11 stated they don’t not handle residents medications and is not aware of any instance where medications were missed or not administered. Staff S12 and S13 stated they are not aware of any instance where a resident was not administered his/her medication. On January 6, 2026, LPA Manuel Monter interviewed former Wellness director, Angel Bustos, referred to as WD. WD stated he/she isn’t aware of an instance where a resident was not administered their medication. On January 6, 2026, LPA Manuel Monter interviewed former Memory Care Director Diana Salah, referred to as MC. MC stated isn’t aware of an instance where a resident was not administered their medication. MC stated he/she is aware of the allegation that R1 was not given his/her medication. MC stated R1 did receive his/her medication that day. The Department reviewed R2’s Medication Administration Record (MAR), dated August 2025. Based on the MAR Medication M1 and Medication M2 are to be administered at 9:00am. The MAR states M1 and M2, were given on august 17, 2025. Furthermore, both M1 and M2, instructions state both these medications need to be administered daily, but do not specify a specific time the medication needs to be given by. On February 5, 2026, LPA Manuel Monter randomly audited 3 resident’s medications (R15-R17). LPA audited the medications by cross referencing the medication bottles/containers and cross referencing with the Centrally Stored Medication Record and Medication Administration Record. 2 Out of 3 residents Medications reviewed (R15 & R16) had inconsistencies. On February 11, 2026, LPA interviewed Wellness Director (WD) Trisa Cysewski and Administrator Camille Burke why there was inconsistencies with R15 and R16's medications. Administrator Burke and Wellness director Cysewski stated they didn't know there was discrepancies. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.