It is alleged that resident has fallen twice at the facility and that staff did not properly supervise resident even though they knew resident was a fall risk.

Staff deny the allegation. Interviews with (9) out of (9) staff revealed that staff are conducting safety checks and are providing proper care and supervision for residents to help prevent falls. Staff indicated that residents who are at risk of experiencing falls are provided with extra monitoring. Staff further indicated that the facility follows protocol which consists of residents being evaluated for injuries and if needed, are sent to the hospital, when experiencing a fall. Interviews with (6) out of (9) staff indicated that R1 experienced a fall on 12/27/2025 and on 1/16/2026 in R1’s room. During both incidents, R1 was checked for injuries immediately after staff responded to R1’s calls for help. R1 stated that they were not hurt and staff observed that R1 was able to move their extremities. Staff indicated that during both incidents, R1refused medical care after it was offered by staff and staff continued to monitor R1 for any changes in condition. Staff further indicated that R1 will attempt to get out of bed without requesting assistance; however, staff continue to educate R1 on the importance of calling for help when R1 needs help getting out of bed by using their call button before trying on their own. Staff stated that R1 can make their needs known. However, staff indicated that R1 gets agitated and wants to transfer from their bed to their wheelchair independently, even though R1 needs minimal assistance during transfers. Interview with R1 indicated that staff check on R1 during their rounds every two hours or more and that staff help R1 get in and out of bed when needed. Interviews with (9) out of (10) residents indicated that staff are conducting safety checks and provide them with support to prevent falls. Residents also indicated that staff are proactive if they need medical attention by calling their doctor or emergency services. Review of R1’s Care Plan indicates that R1 transfers independently, but Caregivers and Med-Techs can assist when needed. R1’s Physician’s Report notes that R1 can transfer to and from bed and does not have any motor impairments.

Staff and resident interviews, and review of R1’s records, could not corroborate the allegation that staff did not provide adequate supervision resulting in a resident sustaining multiple falls.

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

It is alleged that resident often complains of pain during transfers and has asked to go to the hospital, but staff did not seek medical care until after two weeks of expressing pain.

Staff deny the allegation. Interviews with (9) out (9) staff indicated that the facility calls emergency services for residents when they are experiencing pain and they request to be sent out to receive medical care. Staff indicated that staff will not wait two weeks to call emergency services for residents who are experiencing pain. Staff further indicated that R1 has not reported experiencing pain during transfers and that R1 can express their needs and will tell staff if R1 has pain and needs medical attention. Interview with S1-S4 indicated that on 1/18/2026 at around 6:00 p.m., R1 reported to staff that R1 was experiencing pain on R1’s rear-end. Staff stated that R1 was offered to be sent out to get medical attention; however, R1 declined to be sent out and stated that R1 would “tough it out.” Staff indicated that they provided R1 with pain medication and informed R1’s doctor who directed staff to monitor R1’s pain levels. Interview with R7, who assisted R1during this incident stated that R1 approached R7 in the Med-Tech room on the same day at around 6:30 p.m. and expressed experiencing 10 out of 10 pain on their rear-end. At this time, R1 requested to be sent out to the hospital. Staff then proceeded to prepare R1 to be transported to the hospital for treatment via Emergency Medical Transportation. During interview with R1, they could not remember the events of the day; however, R1 stated that R1 was sent to the hospital for his pain in a timely manner. Review of charting notes indicated that staff documented initial report from R1 for pain on 1/18/2026 and R1’s eventual transfer to hospital between 6:00 – 6:30 p.m. Review of Special Incident Report received by the department indicated that R1 was transferred to hospital for evaluation and treatment on 1/18/2026 30 minutes after initial report of pain by R1 at 6:00 p.m. Interviews with (9) out of (10) residents indicated that staff help them get medical attention in a timely manner and also help them with follow-up appointments with their doctors.

Staff and resident interviews and record review could not corroborate the allegation that staff did not seek medical attention until after two weeks of resident expressing pain.

***Continues on page LIC 9099-C page 3***

It is alleged that representative was not notified by staff that resident was taken to the hospital.

Staff deny the allegation. Interviews with (5) out of (5) staff indicated that staff provide timely notification to family members, conservators, authorized representatives, Hospice Services or other responsible parties when residents are sent to the hospital for evaluation and treatment, as long as residents give the facility consent to inform. Staff revealed that R1 is self-responsible and has not authorized the facility to notify anyone if R1 is hospitalized or has experienced other unusual incidents. Staff further indicated that R1 can update at any time, their “Point of Care” information to allow facility staff to inform anyone R1 appoints as person who can be notified regarding hospitalization or other incidents experienced at the facility. Interview with R1 revealed that R1 called their family member when admitted to the hospital 1/18/2026 but did not provide further details. R1 indicated that staff did a good job in sending them to the hospital for care and to made their return to the facility from the hospital easy. Review of R1’s Identification and Emergency Information (LIC 601) form, does not list relatives or friends in section: Other Persons to be Notified in Emergency. Interviews conducted with (9) out of (10) residents indicated that the facility does a good job in maintaining communication with their authorized representatives and have no concerns.

Staff and resident interviews and record review could not corroborate the allegation that representative was not notified by staff that resident was taken to the hospital.

Staff did not provide emergency medical personnel with resident’s medical information.

It is alleged that staff did not send medical information with resident when resident was transferred to the hospital.

Staff deny the allegation. Interviews with (5) out of (5) staff revealed that they follow policy and procedures when sending out residents to the hospital when emergency services arrive. Staff indicated that residents are sent out to the hospital during emergencies with an “emergency packet” which includes their status of vitals taken by staff during assessment, Facesheet, medication lists and Physician Orders for Life-Sustaining Treatment (POLST) if applicable.

***Continues on LIC 9099-C page 4***

Staff and resident interviews could not corroborate the allegation that staff did not provide emergency medical personnel with resident’s medical information.

Staff withheld resident’s personal funds.

It is alleged that staff did not give resident’s funds to a person (P1) since resident was not returning to the facility after hospitalization.

Staff deny the allegation. Interview with S1 indicated that P1 is not authorized to receive R1’s funds because they are not the payee or authorized to manage R1’s funds. S1, who oversees managing residents’ funds, revealed that P1is not authorized to receive R1’s funds because the facility is named as the payee on the Social Security Administration check for R1’s funds. S1 stated that they follow protocol that states that unused resident funds must be sent back to the Social Security Administration office. S1 indicated that per communication S1 had with R1 during hospitalization, there was no need to re-route R1’s funds which pay R1’s facility fees to the Social Security Administration because R1 was planning on returning to the facility after R1’s recovery. S1 indicated that R1’s diagnosis was not going to prevent R1 from returning to the facility and therefore, the funds were going to be used to continue payment of R1’s monthly facility fees. S1 indicated that R1 returned to the facility after their recovery on 2/25/2026. S1 further indicated that R1’s monthly fees have been paid and R1’s account is up to date with payments. Interview with R1 revealed that R1 has returned to live at the facility after their hospitalization. R1 stated that the facility is managing their funds appropriately and has no concerns. Interviews with (9) out of (10) staff indicated that facility staff are managing their funds appropriately. Staff and resident interviews could not corroborate the allegation that staff did not give P1 resident’s funds since resident was not returning to the facility after hospitalization.

***Continues on LIC 9099-C page 5***

It is alleged that staff wheeled resident to the dining room to eat but his clothing and wheelchair were soiled with feces because staff did not change him.

Staff deny the allegation. Interviews with (6) out of (6) staff deny the allegation. Interviews with staff revealed that residents get help with incontinent needs to ensure residents are dry and comfortable. Staff indicated that R1 requires “full care” for incontinent needs and is assisted during shift rounds made by caregivers, and as needed in between checks. Staff further indicated that residents could request help with diapering and other personal hygiene tasks from caregivers at any time by using their call button. Interviews with S1-S4 indicated that R1 was not wheeled into the dining room with feces soiled wheelchair. S1-S4 indicated that R1 had a bowel movement during R1’s meal in the dining room and feces seeped out of R1’s incontinence briefs. S1-S4 indicated that S4 immediately wheeled R1 back to their room to clean R1. Interview with R1 indicated that their incontinent needs are being met by staff and staff promptly change R1 into dry briefs when needed. R1 further indicated that they do not have any concerns with their incontinent care. Interviews with (6) out of (10) residents with incontinent needs are checked by staff every one to two hours and they are being changed accordingly. Residents also indicated that staff do not leave them in soiled briefs. During tour of the facility, LPA observed sufficient incontinent supplies. LPA, also visited R1’s room and did not observe soiled surfaces or incontinent odors. Interviews with staff and residents and LPA observations, could not corroborate the allegation that staff did not assist resident with incontinent care needs in a timely manner.

Staff did not ensure resident was adequately fed.

It is alleged that resident weighed 126 pounds because staff would not assist resident with eating.

Staff deny the allegation. Interviews with (9) out of (9) staff indicated that residents are being fed full meals and are also provided with snacks throughout the day. Staff indicated that they monitor residents’ appetite patterns for any changes, however, R1 has not experienced any loss of appetite and eats well. Staff further indicated that R1 eats in the dining room every day and does not miss any of their meals. R1 is provided with secondary portions when requested and has no impairments to prevent them from eating independently, although staff can assist if R1 needs assistance. LPA reviewed R1’s file and observed that there were no major fluctuations in weight from admission on 3/2/2023 to the present. R1’s weight has been between 125 – 130 lbs. Weight record does not indicate any significant drops of weight since admission.

***Continues on LIC 9099-C page 6***

Interviews with staff and residents and record review could not corroborate the allegation that staff did not ensure resident was fed adequately.

Based on interviews, observation, and record review, 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.