It was reported that when Resident 1 (R1) first moved into the facility, an RN assisted them with oxygen use and supplies, now staff told R1 they are not allowed to help with oxygen.

LPA reviewed an invoice from an oxygen supply company dated 11/12/2025 which states R1 received a supply of oxygen equipment (concentrator and other supplies). LIC602 Physicians Reports dated 02/16/2022 and 02/17/2026 state that R1 is able to administer their own oxygen. Care Plan dated 08/25/2025 states that R1 requires assistance with regular breathing treatments and R1 is independent with their oxygen.

Admission Agreement for R1 dated 12/10/2022 states that the facility does not provide higher levels of care such as nursing.

Resident 1 stated they can manage their oxygen but if the breathing tubes are not on properly or it falls on the floor they may not be able to grab them.

Administrator stated that R1 manages their own oxygen and staff do not assist R1 with their oxygen.

It was determined that R1 can manage their own oxygen but would benefit from more frequent checks by care staff to ensure that their oxygen lines have not fallen off or become stuck in the wheelchair. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that Resident 1 (R1) fell and remained on the floor for several hours, calling for help from approximately 1:30 a.m. to 5:00 a.m on 12/17/2025.

LPA observed R1’s room to be very cluttered with minimal clearance for ambulation.

LPA reviewed an incident report that was submitted on 12/18/2025 which reports on 12/17/2025 at 4:00 AM R1 was found on the floor of their apartment. R1’s pendant was on the floor under their wheelchair. R1 was not wearing their oxygen when discovered. R1 was transported via EMS to the hospital and admitted for treatment. LPA reviewed R1's pendant response times which show on 12/16/2025 10:30 PM R1 pressed their pendant. R1 did not press their pendant again on 12/16/2025 or 12/17/2025.

Resident 1 stated they fell and pressed their button at 1:00 am and no one came in until the shift change. R1 stated they called out for hours.

Administrator stated On 12/17/2025 around 4:00 am one of the care staff went to R1’s room to give them their medication and they found R1 on the floor. States the 4:00 AM medication dispensing is at R1's request. States that depending on R1's current needs their checks are increased, staff would not check on a resident unless their pendant has been pressed. Before R1 fell they were not yet on alert charting which increases their checks but they are now on frequent checks.

It was determined that on 12/17/2025 R1 did fall and was found by staff at 4:00 AM. R1 was not on alert charting prior to the date of the fall on 12/17/2025. Per documentation R1 did not press their pendant to alert staff after 10:30 PMon 12/16/2025 or in the early morning hours of 12/17/2025. This allegation is unsubstantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of the evidence has not been met; therefore, the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED

No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was provided to Executive Director Brian Moore.