Belmont Village Calabasas.

Licensing Program Analysts (LPA) Zabel Chochian arrived at this facility to continue the required annual inspection initiated on 3/10/2026. Upon arrival LPA met with the Executive Director (ED), Cynthia Dachenberg and reason for the visit was stated. Beginning at 1pm the LPA and the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Kitchen: Dining is located on the first floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was available for viewing and the facility offers daily specials and a standard selection at every meal. Sufficient snacks and beverages observed. Facility is also stocked with sufficient emergency food and water supply. A digital system is used to capture residents prescribed diets, allergies, and food preferences. The facility is a three (3) story building. Resident rooms are located throughout three floors. The neighborhood (memory care unit) is located on the first (1st) floor; Circle of Friends units and assisted living units are located on the second (2nd) and third (3rd) floors. Common spaces on the first floor include the reception area/lobby, bistro, dining room, and fitness room. The remaining floors each have their common spaces for activities, and all observed appropriately furnished. All activity rooms and theater appeared clean. Activity schedules are posted throughout the facility. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 02/11/2026. Annual Fire alarm/sprinkler system was tested on 3/21/2025 by West Coast Fire. According to ED and records reviewed the annual inspection was completed and repairs were made last week; they are wait for a retest.Copy of the retest/inspection will be sent to the department once completed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Resident Units: The LPA toured ten (10) randomly selected rooms throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Restrooms: The resident units and common area restrooms observed fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the resident room tours LPA interviewed ten (10) residents. The water temperature was tested throughout the visit including resident unit restrooms and public restrooms. Hot water measured between required range (105*F-120*F) in resident unit restrooms. MEDICATION: Medication review started at 2:30p.m . The LPA reviewed medications for two residents during the visit. Medications are centrally stored and inaccessible to residents in the Wellness Center located on the second floor. Two out of two resident medications reviewed; residents medication matched centrally stored medication record; one medication current used by resident that was filled in 2025 was missing the centrally stored record. According to staff and ED the record was pulled and filed in storage to thin out the current file. Staff and ED stated that they will pull the records from storage and moving forward staff will ensure that centrally stored medication records with medication resident is currently taking stay in the residents records. Memory care unit exit doors and fence gates observed locked and not a delayed egress system. ED received information that the memory care unit is a locked perimeter with no delayed egress on the exit doors. Follow-up needed to clarify if the facility memory care is cleared for locked perimeter or delayed egress. Fire clearance dated 2/16/2018 indicates "Delayed egress/locked perimeter approved for memory care". No deficiency cited during today's visit. Exit interview conducted. A copy of the report was provided.

Licensing Program Analysts (LPA) Zabel Chochian arrived at this facility to conduct a required annual visit. Upon arrival, LPA observed residents in the dining and common area. All required postings observed near the residents mail box area. LPA met with the Executive Director (ED),Cynthia Drachenberg and reason for the visit was stated. During the visit, LPA began the annual inspection with the following: RECORDS REVIEW: Personnel records were requested for review. Beginning at approximately 11:30a.m. LPA reviewed ten (10) personnel records for, but not limited to job application, health assessments, TB results, criminal record clearances, first aid/CPR certification and required training. Staff files reviewed all had required records. Resident records were requested for review. At approximately 1p.m. LPA reviewed twelve (12) resident files for, but not limited to admissions agreements, medical assessment, updated appraisals, and personal rights. Two (2) out of the twelve resident files reviewed required updated medical assessments. ED stated that they will inquire and check their backlog filing for those identified missing records. LPA reviewed facility's Infection Control Plan, Emergency and Disaster Plan at approximately 3:30pm. Due to time constraints, the LPA will return at a later date to continue the annual inspection. No health and safety issues observed during today's visit. Exit interview held and copy of report provided.

The chef reported that servers/staff not preparing/handling food are not required to wear hairnets or gloves. Sufficient supply of gloves and hairnets observed in the kitchen. LPA reviewed the facility's most recent dietary audit report dated 12/12/2025. Report revealed that facility is in compliance and meet standards in Personnel hygiene - food handled properly; hair restraints and gloves used (worn in food production areas). On 2/24/2026, LPA conducted a subsequent complaint visit. LPA conducted random interviews with four (4) staff; LPA also met with and interviewed twelve (12) random residents from approximately 12pm-2:30pm. Staff interviewed reported that they also eat the facility food 3-4 times in the week and they reported no issues with the food received. Staff denied ever finding any hair in their food. Resident interviews revealed that the food service is good and they never experienced any issues with "hair in their food". Twelve out twelve residents interviewed expressed being very satisfied with the food service and dining experience. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation " Staff did not ensure food was free from contamination" is deemed unsubstantiated at this time. Exit interview held and copy of report provided.

Licensing Program Analysts (LPAs) Quoc Huynh and Emily Peraldi arrived unannounced at 10:20AM for a Case Management Annual Continuation visit from 03/12/2025. The LPAs met with Executive Director (ED) Nancy Nelson and explained the reason for the visit. Entrance interview conducted. During the visit, LPAs conducted review of the following: RECORDS: Personnel records were reviewed at 11:00AM. The LPAs reviewed six personnel records for, but not limited to job application, health assessments, TB results, criminal record statements and clearances, and first aid/CPR certification. Staff files reviewed were in compliance with regulation at this time. Resident records were reviewed at 11:55AM. The LPAs reviewed five files for, but not limited to admissions agreements, medical assessment, and updated appraisals. Resident records reviewed were in order at this time. At 12:30PM, the LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility was observed to be in compliance at this time. Fire alarm/sprinkler system was last tested on 03/21/2025 by West Coast Fire with a follow up to be scheduled to close the inspection. Report Continued on LIC 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 MEDICATION: Medication reviews occurred at 12:50PM (Memory Care unit) and 1:25PM (2 nd floor Wellness Center). The LPAs reviewed medications for four residents during the visit. Medications are centrally stored and inaccessible to residents in the Wellness Center located on the second floor. Four out of four resident medications reviewed were documented and stored in compliance with regulation at this time. Four residents and two staff were interviewed. No complaints noted. No deficiency cited. Exit interview conducted. A copy of the report was provided.

Licensing Program Analysts (LPA) Zabel Chochian arrived at this facility to conduct a required annual visit. At approximately 10:30 a.m., the LPA met with the Executive Director (ED), Nancy Nelson and reason for the visit was stated. Entrance checklist provided and reviewed with ED. Between 11:15 a.m. and 1:45 p.m., the LPA and the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The facility is a three (3) story building. Resident rooms are located throughout three floors. The neighborhood (memory care unit) is located on the first (1st) floor; Circle of Friends units and assisted living units are located on the second (2nd) and third (3rd) floor. Common spaces on the first floor include the reception area/lobby, bistro, dining room, and fitness room. The remaining floors each have their common spaces for activities, and all are appropriately furnished. All activity rooms and common spaces appeared clean and in good repair. A theater and salon are located on the third (3rd) floor. Activity schedules are posted throughout the facility. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 01/27/2025. Fire alarm/sprinkler system was tested last on 2/19/2024 and is scheduled for 3/24-25/2025. Resident Units: The LPA, and ED toured twelve (12) randomly selected rooms throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Restrooms: The resident units and common area restrooms observed fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The water temperature was tested throughout the visit including resident unit restrooms and public restrooms; and water measured between 117.0– 120.2 degrees Fahrenheit. Throughout the resident room tours, LPA interviewed four (4) residents. Outside areas: There are multiple outdoor patios equipped with furniture for resident use as well as covered areas for resident use. The in-ground pool is appropriately fenced. (Continue to LIC809c). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Kitchen: Dining is located on the first floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was available for viewing and the facility offers daily specials and a standard selection at every meal. Sufficient snacks and beverages observed. Facility is also stocked with sufficient emergency food and water supply. A digital system is used to capture residents prescribed diets, allergies, and food preferences. Documentation obtained: Copy of the liability insurance, resident roster, staff roster (LIC500), Infection Control Plan, copy of menu, last dieticians report vehicle service record Emergency and Disaster Plan. Due to time constraints, the LPA will return at a later date to review staff and resident records including medication procedures and record keeping. No health and safety issues observed during today's visit. Exit interview conducted and copy of the report was provided.

Staff was interviewed at approximately 4pm and facility records were reviewed. Additional attempts were made to reach the reporting party on 05/10/2024; 08/15/2024; 11/19/2024; and on 01/14/2025 but was unsuccessful. A subsequent visit was conducted on 02/19/2025, and interviews were conducted with six (6) staff from approximately 11:30am-3:00pm; additional records pertaining to former resident (R1) were requested and reviewed; interview conducted with potential witnesses. Following is a summary of the allegations and investigation finding: Regarding Allegation: Facility failed to seek timely medical attention for resident resulting in a questionable death. Information was provided that resident #1 (R1) was observed showing signs of a stroke on 01/09/2024 and facility did not seek timely medical attention for R1; resident passed away within 48 hours. No additional information was provided about the resident’s questionable death identifiers. Several attempts were made to reach the reporting party to obtain additional information however no response was received. To investigate the allegation, the LPA reviewed the Department’s database for Death Reports (LIC624 A). The LIC 624A report received in our office on 01/12/2024, indicate the manner of death to be of natural causes due to conditions contributing to death. Facility staff interviewed reported that R1 was not observed showing any signs of a stroke prior to death. R1 was admitted to Affinity Healthcare Resources on 12/30/2023. The hospice notes reflect that due to R1’s poor prognosis and declining condition, family wished to decrease hospitalization and treatment and opted for hospice care for palliative measures and symptom management. R1 was seen by the hospice nurse for routine skilled nursing and support services. Resident was placed on comfort care level of care for respiratory distress and pain; discharge summary obtained from Affinity Healthcare Resource noted resident #1’s terminal diagnosis of Athscl Heart disease of native coronary artery. On 01/11/2024, resident expired peacefully with hospice nurse and family at bedside; immediate cause of death documented as “cardiopulmonary arrest”. Based on the information obtained through record review and interviews; the allegations “Facility failed to seek timely medical attention for resident resulting in a questionable death”, is deemed Unsubstantiated at this time. (Continue to LIC9099c) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding allegations: 1) Staff inappropriately handled the residents resulting in bruising; 2) Staff did not provide a resident care service as agreed; 3) Residents sustained pressure injuries due to neglect; 4) Resident fell due to staff neglect; 5) Staff did not respond to a resident's calls for assistance; 6) Staff violated residents’ personal rights; 7) Facility retained a resident requiring a higher level of care. Reporting party was contacted several times to gather supporting information for these allegations and no response was received; no resident names or dates of alleged incidents was provided. To investigate these allegations LPA conducted interview with facility ED and staff; toured the memory care unit and assisted living side. Residents of the “Neighborhood” were unable to be interviewed due to lack of capacity. Random interviews were conducted with residents residing in the assisted living side and other potential witnesses; no mistreatment or neglect was reported. LPA also reviewed facility incident and death reports from 11/2023 – 1/2024; no discrepancies found. ED and Director of Resident Care Services stated that facility did not retain any resident requiring higher level of care; no resident retained with pressure injury greater than stage 2. Based on the information obtained through facility record review and interviews conducted allegations listed above are deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided.

Report Continued from LIC 9099... It was alleged that staff did not meet a resident’s laundry needs and staff did not ensure that a resident’s room was free of trash. It was reported that a resident was wearing wet clothes, blankets appeared wet, and the laundry hamper was full of soaking wet clothes. Additionally, the wastebasket in the resident’s room bathroom was full and had not been emptied. During a walkthrough on 03/05/2024, the LPA observed five (5) random resident rooms in the Neighborhood. The rooms appeared relatively clean, linens were not soiled, or wet, dirty laundry was observed in the hamper, and trash cans were not overflowing. Record review and interviews conducted revealed that housekeeping is scheduled at least once a week for each bedroom in memory care. Staff members stated that they are assigned a group of residents to care for daily, and some of their duties include cleaning and maintaining the residents' rooms and doing their laundry. Staff also mentioned that resident bedding is typically changed every few days but will be changed sooner if needed. Interviews further revealed that staff are responsible for taking out the trash; however, any shift can handle taking out the trash as it is included in their assignments. Additionally, interviews with residents corroborated staff statements, as residents confirmed that staff maintain their rooms clean. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “staff did not meet a resident’s laundry needs” and “staff did not ensure that a resident’s room was free of trash”. Therefore, these allegations are deemed Unsubstantiated at this time. It was also alleged that staff falsified a resident’s care documents. It was reported that staff are signing off on completing tasks and caring for residents needs when in fact they have not. Interviews with staff revealed that each team member is assigned specific duties to complete while caring for the residents on a daily basis. Staff sign off after each task is completed to inform the next shift about what still needs to be taken care of. During shift changes, staff typically communicate with one another about tasks that are still pending for the day. Staff mentioned that during crossover, they inform the incoming team if any laundry or cleaning is still required for their assigned residents. Additionally, staff reported that there have been no issues with other shifts failing to complete the tasks assigned to them. Based on interviews conducted with staff, the Department has insufficient evidence to support the allegation of “staff falsified a resident’s care documents”. Therefore, this allegation is deemed Unsubstantiated at this time. Report Continued on LIC 9099C... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Report Continued from LIC 9099C... It was further alleged that staff did not prevent resident’s from playing in their feces. It was reported that due to lack of staff, residents were left unattended which resulted in residents playing in their feces. Interviews conducted with staff revealed that incontinent residents are typically changed every two (2) hours or sooner if needed. Staff stated that they have never witnessed or encountered any residents playing with their feces. However, there have been occasions when a resident has placed their hand in their pants, resulting in their hand being covered in feces. Despite this, staff have never observed the resident playing with or smearing the feces. Staff reported that they wash the resident's hands and change them, unless the situation is more severe, in which case they will give the resident a shower to ensure they are thoroughly cleaned. Based on interviews conducted, the Department has insufficient evidence to support the allegation of “staff did not prevent resident’s from playing in their feces”. Therefore, this allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. Report was reviewed and copy issued.

On 04/03/2024, LPA Chochian conducted a complaint investigation visit to the facility above from 10:00am to 11:00am. During this visit, LPA requested and received relevant documentation pertinent to the complaint allegation for record review. LPA Brian Phillips reviewed the documentation. R1’s physician report states that R1 has a primary diagnosis of Alzheimer’s dementia including the loss of cognitive functions. The documented secondary diagnosis for R1 is atypical depressive disorder with negative mood changes due to changing environments. Medical admission assessments by the facility documented that R1 was forgetful/confused with mood/personality changes. The facility admission agreement was signed and dated by the responsible party of R1 on 07/29/2022 prior to R1’s move in date of 07/31/2022. This admission agreement states that the facility can terminate the agreement upon thirty (30) days written and verbal notice to the resident/responsible party if it is determined that the resident has a need not previously identified and a reappraisal has been conducted with the determination that the facility is no longer appropriate. The admission agreement states that the facility is not designed or licensed to provide higher levels of care for serious mental or emotional disorders. If it is determined a resident is a danger to themselves or others and it is inappropriate for a resident remain in their apartment, then they will be asked to leave the facility and the admission agreement will terminate. The facility may discharge a resident if they present an immediate physical threat or danger to themselves or others. A resident may also be discharged if their dementia/mental disorder results in ongoing behavior that requires care and supervision greater than the facility can provide. Interview and documentation provided by Executive Director revealed that on 01/25/2024 the facility held a meeting with R1’s family to discuss R1’s changes in behaviors and possible evaluation for R1’s changing medical condition. R1’s doctor then ordered R1 to be admitted to a psychiatric hospital for further evaluation. On 01/28/2024, R1’s family, who had been in communication with R1’s doctors, indicated a bed was open in the hospital unit and R1’s family took R1 to the psychiatric hospital for a 14-day time period. All licensing agency interviews with facility staff and the responsible party of R1 indicated that the resident would not be returning to the facility after R1 was evaluated/reappraised while in the psychiatric hospital. Although Reporting Party indicated it was the facility that did not allow the resident to return, the Executive Director provided documentation and notes indicating the hospital social worker suggested to R1’s family discharging R1 to a Skilled Nursing Facility (SNF) for further medication adjustments with a doctor onsite. On February 10, 2024, R1’s family member verbally told the facility R1 would likely not be returning to the facility. R1’s family member then began removing R1’s personal belongings from the facility on 02/20/2024. R1’s family member reported to the facility on 02/23/2024 that R1 was discharged to a SNF. On 02/29/2024, R1’s family Report Continued on LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 member confirmed R1’s room at the facility was fully vacated, thus terminating the residency contract. Although R1 did not return to the facility following a stay at the psychiatric hospital, it is unclear whether the facility refused the resident to return or if the family and/or hospital social worker made the decision for R1 not to return. R1 was discharged to a SNF, which is a level of care the facility cannot provide per Title 22 regulations. Based on the information gathered, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “facility illegally evicted a resident in care” is deemed UNSUBSTANTIATED at this time. On the allegation: Facility did not issue a refund to a resident in care. It is alleged that R1 had their personal belongings removed from the facility on 02/25/2024 after being in a psychiatric hospital beginning on 01/28/2024. The allegation requests a refund for the days R1 was out of the facility from 01/28/2024 to 02/25/2024, with the resident not returning to the facility. LPA requested and received a copy of the documented facility residence and services agreement/admission agreement. The facility admission agreement was signed and dated by the responsible party of R1 on 07/29/2022. The facility admission agreement has a refund policy regarding the vacating of an apartment, and the refund of unused portion of monthly fee. The monthly fee is defined in the admission agreement as total combination fee of apartment fees and service plan fees. Supplemental support services/additional services are offered for an additional fee. According to the facility admission agreement signed/dated by the responsible party of R1, the facility fees did not include any additional/supplemental support services for R1 while in care. The monthly fee charged to R1 was the combined apartment fee and the service plan fee. If the admission agreement is terminated, the resident must vacate the apartment and remove all property from it. The resident or their responsible party will remain liable for the monthly fee until the effective termination date and all the resident’s property is removed from their apartment, whichever occurs later. The facility may also charge a resident a property storage fee if they fail to remove their personal belongings by the effective termination date. Following the termination of the admission agreement, the facility will pay the resident or their responsible party a refund equal to any amount owed, minus certain conditions including any expenses incurred to store resident’s property that was not removed upon vacating the apartment. According to the facility admission agreement, R1 is liable for the monthly facility fee until all R1’s property is removed from Report Continued on LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 their apartment, as that occurred later than the effective termination date. All licensing agency interviews with facility staff and the responsible party of R1 indicated that the resident would not be returning to the facility following R1's stay in a psychiatric hospital beginning on 01/28/2024, but R1’s property was not removed from the facility until 02/25/2024 by their responsible party, who then notified the facility on 02/29/2024 that all R1’s personal belongings were out of their apartment. Therefore, R1’s responsible party is liable for R1’s monthly fee until 02/29/2024 and the facility is not required to issue a refund for the days R1 was out of the facility from 01/28/2024 to the date R1's belongings were removed. However, LPA Dulek was informed during the subsequent complaint visit that the facility chose to issue a refund to R1's responsible party, which was issued sometime toward the end April or beginning of May 2024. Based on the information gathered, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “ facility did not issue a refund to a resident in care ” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. Copy of today's report was provided.

Continued from LIC 9099 On 02/08/2024, LPAs V. Conway and K. Dulek conducted an initial 10-day visit. During the visit, LPAs conducted a tour of the physical plant at 10:15 A.M. LPAs also conducted interviews with Administrator, staff, and several residents between 10:15 A.M. to 11:20 P.M and obtained pertinent documents relevant to the investigation. On 08/28/2024, LPA V. Conway interviewed a random number of residents and staff. Additionally, LPA attempted to contact the Reporting Party (RP) on 02/06/2024, 02/07/24 and on 08/24/2024, however, was not successful. Information gathered during the course of the investigation reflected staff do not force residents into taking showers. If a resident does not want to shower, staff will try to verbally convince them by explaining how beneficial it is to get their bodies clean. Additionally, staff stated that they are aware of the residents’ personal right to refuse and if the resident does refuse, staff will notate the refusal on the daily staff notes and then inform Med-Techs/Director of Nursing. The Director of Nursing will then in return notify the residents responsible party and the primary care physician (PCP). Interviews with residents revealed that they are well taken care of and had no concerns. Furthermore, residents stated that no staff try to make them do things against their will. Record review of the facility shower schedule consisted of a schedule for each resident and a bath/shower monitoring form that staff use to document when a resident refuses a shower or bath. Based on the information gathered during the course of the investigation, the Department does not have sufficient evidence to support the allegation, therefore the allegation "Staff are forcing residents into the shower while in care" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted. A copy of the report was provided.

The complaint alleges that R1 sustained unexplained bruising while at the facility. Record review revealed that R1 had a diagnosis of dementia and resided in the facility's memory care unit. While residing at the facility, staff indicated that R1's dementia progressed and that R1's behaviors escalated. R1 became difficult to care for, as R1 became more aggressive with staff and refused care. Nurse's notes reviewed indicated R1 had an unwitnessed fall on 01/12/2024, which resulted in staff calling 9-1-1 and obtaining outside medical treatment for R1. Staff interviewed indicated that R1 was aggressive when EMTs arrived to take R1 to the hospital. R1 was large in stature and that 4 EMTs were observed holding R1 to the gurney while taking R1 out of the facility. Resident returned from the hospital the same day with no known injuries noted. On 01/16/2024 and 01/17/2024, bruising was noted on R1's forehead, nose and under eye. Staff notes indicate family was informed of the noted bruising. On 01/19/2024, additional bruising was noted on R1's arms, hip and back and R1 was taken to urgent care for observation of the bruising. Text messages between facility and PCP were provided to LPA indicating the bruising and request for outside medical treatment. Staff interviewed indicated that at the time of the allegation, R1 had increasing paranoia and possible hallucinations. R1 reported not trusting care staff and refused full body showering. Therefore, staff was unable to clearly observe R1 for physical changes or bruising timely, as R1 refused observation. As R1 refused observation and a full body check for injuries, it is difficult to ascertain when the bruising occurred and whether the resident was present at the facility during the time of the alleged bruising. Additionally, as the bruising was noted but of unknown origin, there is no way of knowing how the bruising occurred and whether it was a result of a lack of care and supervision at the facility. Both residents and staff interviewed indicated they have never heard of or observed any staff being rough with the residents and residents feel safe at the facility. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "resident sustained unexplained bruising" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted. A copy of the report was provided.

Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management visit regarding an incident which took place on 10/18/2023 involving Resident 1 (R1). LPA met with Executive Director (ED) Nancy Nelson and Resident Care Director (RCD) Zara Khatchatrian, RN, and explained the reason for the visit. At 10:00 a.m. LPA interviewed the ED and RCD, regarding the incident report they submitted for R1. On 10/18/2023, R1 was not responding to stimuli and staff called 9-1-1. R1 was admitted to the hospital with an initial diagnosis of severe dehydration. R1 was admitted to the facility in July of 2023. Prior to moving into the facility, R1 was at home with a 24/7 private caregiver. Upon admission to the facility, R1 was eating finger foods but started losing their appetite. Staff encourage residents to eat and drink but R1 would eat and then remove the food from their mouth. R1 also did not like to drink much. At 10:30 a.m. LPA reviewed R1's facility file. After their stay at the hospital, R1 returned to the facility on 10/21/2023. The discharge paperwork from the hospital stated R1 was admitted for sepsis. R1 returned to the facility from the hospital with redness in a few areas. R1's physician ordered home health. A home health nurse visits three times a week for R1's rash to assess and ensure the redness does not progress further. R1's physician also ordered an appetite stimulant. At 11:28 LPA toured the memory care unit and met R1. LPA interviewed the Memory Care Coordinator at 11:31 and interviewed a caregiver at 11:35 a.m. The staff encourage residents to drink water, juice, and other beverages they enjoy. Beverages are offered at all meals, snacks, after activities and during medication pass. R1 has been prescribed a pureed diet and is eating well but still does not like to drink fluids. They continue to offer R1 different beverage options and encourage hydration. Based on the information obtained, it appears R1's needs are being met based on R1's care plan and medical orders. No deficiencies observed. Exit interview conducted. A copy of the report was provided.