It was alleged that staff do not seek medical attention for residents in a timely manner. This investigation consisted of interviews with facility staff, and records review. On 02/26/2026 an initial visit was conducted to the facility by LPA Tomayo, resident and facility records were obtained. On 05/13/2026 SIA Belman conducted an interview with facility staff (S1) who reported that on 01/25/2026 at 1:55 AM resident (R1) fell while ambulating inside of their room. Staff (S2) stated that (R1) should have been transported to the hospital sooner as staff observed visible injuries, R1 was not transported until 1:40 PM on 01/25/2026. Additional interview with facility staff (S2) stated that residents are assessed for injuries and transported based on the severity of the injury. Staff (S2) further stated that the facility has a responsibility to request emergency services when there are visible signs of injury. Further interview with the Memory care coordinator stated that residents who are considered a fall risk are monitored closely, stating that when resident falls occur, facility medication technicians assess residents injuries and contact emergency services immediately. Records review indicated that on 01/25/2026 resident (R1) had an unwitnessed fall in which the resident was not immediately transported to the hospital due to R1’s family request, it was revealed that R1 sustained injuries due to their fall. Although R1’s family declined immediate transport, the facility remained responsible for ensuring R1 received an appropriate medical evaluation and failed to obtain further medical guidance following the fall. Based on interviews and records reviewed, the allegation is substantiated. The facility did not ensure R1 received necessary and timely medical attention following an unwitnessed fall that resulted in visible injuries. This was observed to be not in compliance with Title 22 regulation 87465(a)(2).

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Allegation: Staff falsify incident reports regarding residents in care.

It was alleged that Staff falsify incident reports regarding residents in care. This investigation consisted of interviews with facility staff, and a review of records. On 06/30/2026, LPA Hughes conducted a visit to the facility. Interview with the facility administrator stated that, effective 06/01/2026 they became responsible for submitting incident reports and ensuring incident information is accurately documented based on information communicated by staff. The administrator stated that medication technicians typically report incidents, after which the facility interviews residents and staff, review resident records, and communicates with resident responsible parties. LPA reviewed facility Unusual Incident/ Injury Reports from January through February 2026 for residents (R1) and (R2) which did not reveal evidence of falsified information or inconsistencies to reported incidents. The information documented in the reports was consistent with the information obtained during the investigation. Based on information and evidence obtained the allegation is unsubstantiated.

Allegation: Staff are inappropriately restraining residents.

It was alleged that staff are inappropriately restraining residents. This investigation consisted of interviews with facility staff, and residents in care. On 06/30/2026 LPA Hughes conducted a visit to the facility. Interviewed three (3) facility staff indicated that residents are watched closely, however denied allegations of inappropriately restraining residents. LPA interviewed five (5) residents who did not express concerns regarding being inappropriately restrained or ever observing any residents in care being inappropriately restrained within the facility. Based on information and evidence obtained the allegation is unsubstantiated.

Continuation 9099-C

It was alleged that staff handle residents in a rough manner. This investigation consisted of interviews with facility staff, and residents in care. On 06/30/2026 LPA Hughes conducted a visit to the facility. Interviewed three (3) facility staff who denied ever handling residents in a rough manner or ever observing facility staff handle a resident in a rough manner. LPA interviewed five (5) residents who did not express concerns regarding being handled in a rough manner, or ever observing other residents being handled in a rough or aggressive manner. Based on information and evidence obtained the allegation is unsubstantiated.

Allegation: Staff do not provide activities to residents in care.

It was alleged that staff do not provide activities to residents in care. This investigation consisted of interviews with residents in care, facility observations and records review. On 06/30/2026, LPA Hughes conducted a visit to the facility. Interview with five (5) residents (R6-R10) revealed that the facility provides a variety of activities in which residents actively participate. During the facility tour, LPA observed residents participating in a game of Bingo and later observed a resident group activity led by the facility’s activity coordinator. LPA also reviewed the facility activities calendar, which documented scheduled daily activities consistent with those observed during the visit. Based on information, evidence, and facility observations obtained the allegation is unsubstantiated.