It is alleged that a resident passed away from choking on their food. It is also alleged that resident’s food may have required cutting.

Staff deny the allegation. Interviews with (10) out of (11) staff revealed that R1 did not die from choking on their food and staff also indicated that R1 did not require their food to be cut. Staff stated that R1 did not need any dietary accommodation like cutting, chopping, pureeing, mincing or liquifying their food. Staff indicated that R1 passed away on 11/25/2025 at 9:45 p.m. in R1’s room as R1 rested in bed. Interview with S1, S2, S3 and S10 revealed that S3 called a STAT upon entering R1’s room for a routine wellness check. S3 indicated that R1 was observed gasping for air and immediately radioed base for help with R1. S10 indicated that they immediately answered the STAT call from S3 and observed R1 in bed gasping for air. S10 indicated that they proceeded to elevate R1 to an upright position and started a check for vitals as other staff called 911. S10 could not get a reading from R1’s oxygen and blood pressure due to both being low. S10 indicated that medics arrived shortly after and did not procced to attempt resuscitation due to R1 having a Do Not Resuscitate (DNR) document in place. S1, S2, S3 and S10 indicated that R1 was pronounced deceased at 9:45 p.m. by medics due to “Respiratory Failure.” S2, S3 and S10 indicated that they did not observe any signs of choking or food or other objects in R1’s mouth. Interview with (1) staff indicated that although they were informed by staff that R1 had passed away, (1) staff indicated that they do not know the cause of death of R1. Review of R1’s Care Plan indicated that R1 was on a no sodium diet; however, R1’s food did not require special dietary modifications like chopping, pureeing, mincing or liquifying. Care Plan indicated that R1 is independent and needed no assistance with food intake. R1’s Appraisal Need and Service Plan indicated that R1 “feeds self independently” and dietary needs or dietary accommodations were not observed listed on “Services Needed” section. Interview with R1’s family member (P1) indicated that R1 passed away from ailments R1 had been dealing with for an extended period. P1 indicated that R1 did not die from choking on R1’s food. P1 further indicated that R1 did not need any dietary accommodation like chopping, mincing, dicing or liquifying R1’s food and was on a regular diet which R1 was able to eat comfortably. P1 stated that they have no suspicion regarding R1’s death and that the facility provided appropriate care for R1 till the end of R1’s life. Interviews with R3-R11 indicated that they don’t have concerns with staff neglecting residents. Staff, resident and P1’s interviews, and record review do not corroborate the allegation that resident passed away from choking due to staff not cutting his food.

***Continues on LIC 9099-C page 2***

It is alleged that all facility caregivers are rough when assisting a resident. It is alleged that staff pull and push resident and are rough even though resident is paralyzed on their left side.

Staff deny the allegation. Interviews with (9) out of (11) staff revealed that caregivers are not rough with residents. Staff stated that they do not pull or push residents under any circumstance. Staff indicated that residents are treated with dignity and respect and that they are trained to follow policy and procedures regarding the proper care of residents. Staff further indicated that they are mandated reporters and any suspicion of abuse is reported immediately to the proper authorities. Interview with S3 indicated that they have never been rough, nor pushed or pulled R2. S3 indicated that R2 is treated with respect and dignity. S3 indicated that due to R2s medical needs, S3 takes their time to assist R2 during transfers and helping R2 change their clothes. S3 stated that at times, R2 complains about experiencing pain when S3 assists R2 during transfer from R2’s bed to their wheelchair; however, S3 indicated that S3 is careful when helping R2 by making their move as comfortable as possible. Further information obtained from interviews with S1 and S2 indicated that they have not observed S3 treat R2 or any resident inappropriately. S1 and S2 further indicated that they have not received any reports of S3 treating R2 inappropriately, nor placed disciplinary actions on S3 for misconduct toward residents. Interviews with (10) out of (11) residents indicated that residents are never pushed, pulled or treated roughly by caregivers. Residents also indicated that they are treated with respect and dignity and would report any inappropriate conduct from staff to the authorities. Review of S3’s staff record indicated that S3 does not have any write-ups or disciplinary actions on file for not providing appropriate care to residents or other midconduct. Staff and resident interviews and record review do not corroborate the allegation that staff treat resident roughly by pushing and pulling resident while providing care.

Regarding: Facility restroom is not accessible to wheelchairs.

Is alleged that when resident tries to use the bathroom, their wheelchair does not fit because the door is narrow.

Staff deny the allegation. Interviews with (9) out of (11) staff revealed that R2’s wheelchair enters their bathroom with no difficulty. Staff indicated that R2’s wheelchair can be pushed in the bathroom and can be positioned next to the toilet for a comfortable transfer. ****Continues on LIC 9099-C page 3***

Staff are not responding to resident’s call button in a timely manner.

It is alleged that staff are not responding to resident’s call button in a timely manner. It is also alleged that resident waits one (1) to two (2) hours to be assisted with getting covered with a blanket, getting water, helping resident in the bathroom, and being taken outdoors.

Staff deny the allegation. Interviews with (10) out of (11) staff revealed that staff respond to call button notifications in a timely manner. Staff indicated that staff assigned to conduct rounds in their assigned wings of the facility, respond within five to ten minutes of receiving calls on their radios from dispatch in the font desk. Staff indicated that if the assigned caregiver is not available to answer a call made via call button, front desk staff will dispatch another caregiver to cover for the one who is busy helping other residents. Staff also indicated that R2 and all residents are provided with blankets, water, assistance in the bathroom and help with being taken outdoors when needed. Staff indicated that R2 can move around independently with the use of their wheelchair around the facility and is observed leaving the facility for appointments and errands without help. Interviews with (10) out of (11) residents indicated that staff respond to call button pushes within five to ten minutes. Residents indicated that they have no concerns with caregivers not responding in a timely manner to their calls. Staff and resident interviews do not corroborate the allegation that staff are not responding to call button in a timely manner.

***Continues on LIC 9099-C page 4

It is alleged that resident’s room is cold and resident is not being provided with a comfortable room temperature.

Staff deny the allegation. Interviews with (9) out of (11) staff revealed that the facility is kept at a comfortable temperature for all residents. Staff indicated that each resident room has its own AC/heater unit in which temperature of the room can be regulated by the residents. Staff indicated that residents are free to set the temperature of their room to make it warm or cool. Staff stated that they have not received any complaints regarding resident rooms not sustaining comfortable temperature. Staff further indicated that the facility provides residents with extra blankets if needed. Staff further indicated that R2’s room is equipped with its own heater and R2 can set it at any temperature, and R2 has been provided with extra blankets and sheets. Interviews with (10) out of (11) residents revealed that the temperature in their room is appropriate and have no concerns regarding their room not being at a comfortable temperature. Residents also indicated that they can ask caregivers for extra blankets and will be provided to them if needed. Interview with R2 indicated that R2’s room is cold and staff do not keep it at a comfortable temperature. LPA inspected R2’s room during visit on 12/4/25 and measured the temperature with a probe thermometer. Temperature of the room measured at 78.9 degrees F. LPA also inspected (10) resident rooms at random during today’s visit and temperature was found to be between 78.9-83.4 degrees F. which is within compliance range. During inspection of the rooms, LPA observed the temperature control units to be working properly. Staff and resident interviews and observations do not corroborate the allegation that resident’s room is cold and not at a comfortable temperature.

Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.