Oakmont of el Dorado Hills.

Staff are not providing adequate food service for residents The Department conducted interviews and reviewed facility records, including menus, food service logs, and related documentation. The investigation did not reveal any evidence to support that staff failed to provide adequate food services. Information obtained during the investigation indicated that meals were provided in accordance with established menus and dietary requirements, and that food service operations were conducted consistent with facility procedures. There were no observations, documentation, or credible statements to substantiate the allegation. Therefore, the allegation is determined to be UNFOUNDED. Staff are not providing a comfortable environment for residents Based on resident interviews, there is insufficient evidence to support the allegation. Residents consistently reported that staff are welcoming, helpful, and kind. Residents also stated they are happy living at the facility and feel comfortable in the environment. No evidence was obtained to indicate that staff failed to provide a comfortable living environment for residents. Therefore, the allegation is determined to be unfounded. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff are not keeping residents documents updated Based on documents obtained and statements reviewed, the department determined the Licensee ensured that a complete and current record, including Admission Agreement, Needs and Service plan, Physician’s report etc. was maintained for residents in care. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not respond to the residents pendant call in a timely manner The Department conducted interviews and reviewed facility records, including incident reports, care logs, and related documentation. The allegation did not reveal any evidence to support staff failed to respond timely to residents’ alerts. Information obtained during the investigation indicated that staff responded appropriately and within required time frames when alerted by residents. There were no observations, documentation, or credible statements to substantiate the allegation. Therefore, the allegation is determined to be UNFOUNDED. Facility is not kept free of pests Based on documents obtained and statements reviewed, the department determined that there was insufficient evidence that the facility is not kept free of pests. The facility representative stated that the pest control company comes in monthly, and more often as needed. Four (4) staff and three (3) residents were interviewed and stated they have not seen any pests at the facility. During 05/19/2026 and 06/23/2026 visits, the facility was toured and documentation from the pest control company was provided. Therefore, the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.

Licensing Program Analyst (LPA) Lavinia Muscan arrived on 6/23/2026 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed five resident (5) and five staff files (5). All resident files contained the required paperwork. All staff files contained the required paperwork. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed. Staff training contained the required initial training. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, dining room, hallways, and common areas. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. The disaster drill is current. The administrator's certificate is current. LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector are operational. Fire extinguisher is ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed. LPAs requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to facility.

Staff do not timely respond to the residents alerts The Department conducted interviews and reviewed facility records, including incident reports, care logs, and related documentation. The allegation did not reveal any evidence to support staff failed to respond timely to residents’ alerts. Information obtained during the investigation indicated that staff responded appropriately and within required time frames when alerted by residents. There were no observations, documentation, or credible statements to substantiate the allegation. Therefore, the allegation is determined to be UNFOUNDED . Staff do not provide adequate food service The Department conducted interviews and reviewed facility records, including menus, food service logs, and related documentation. The investigation did not reveal any evidence to support that staff failed to provide adequate food services. Information obtained during the investigation indicated that meals were provided in accordance with established menus and dietary requirements, and that food service operations were conducted consistent with facility procedures. There were no observations, documentation, or credible statements to substantiate the allegation. Therefore, the allegation is determined to be UNFOUNDED . Exit interview conducted. Report left with facility.

Staff not providing medical attention to resident in a timely manner. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Based on five (5) staff and three (3) resident interviews, the typical response time for staff responding to a resident’s call alert ranges from 5 minutes to as soon as possible. Residents interviewed stated they have not had issues with staff not responding timely. Staff interviews indicated that staff usually respond to residents’ call buttons within 5 minutes or sooner. Staff stated they know the protocol on how to address any medical intervention, and residents had no concerns with timely medical attention. Additionally, staff stated that EMS is right around the corner and arrives quickly if needed. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff are not following resident’s care plan. The department conducted interviews regarding this allegation. Record reviews and interviews with staff indicated that staff were aware of residents’ care and service needs based on residents’ needs and service plan. Department review of residents’ documentation; Physicians Report, Service and care plan, and interviews conducted revealed that staff were following resident’s needs and service plan as documented. After review of residents’ files and medical records, department also concluded that facility was following up with residents’ doctor, family and department as needed; therefore, above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.

Staff do not provide adequate food service Based on eight staff interviews (8) and six resident interviews (6) and department observation of the kitchen and meal service, the department found that there was an adequate amount of food for the residents. The food appeared to look appetizing and nutritious, sanitation in the kitchen appeared appropriate, residents said food was good, and portions appeared plentiful. Food supplies in facility were adequate to meet the requirements. Currently, there is no evidence to suggest that staff have failed to provide adequate food service or provide it in a timely manner. Therefore, the allegation is UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff do not properly maintain the facility grounds Based on eight (8) staff interviews, six (6) resident interviews, and department observation, the department observed the facility to be clean and sanitary. During department visits on several occasions, including on 10/07/25 and 10/14/25, the facility did not observe to be unsanitary including resident rooms, common areas and restrooms. Facility grounds were properly operating. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job. Staff interviews indicated that the facility is kept clean and sanitary without any concern; therefore, the allegation is UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with Administrator.

On 10/22/2025, around 09:30 AM, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Lavinia Muscan were present for an informal meeting with Administrator Chad Rogers, Regional VP of Operations Terry Ervin, Senior VP of Health Services Jennifer Sato, Senior Regulatory Director Kevin Wrigley, and Nurse Jimmy Duong, which was held via Teams. During today's meeting, department discussed complaint history, including the complaint dated 09/25/2024. Facility representatives discussed the updated fall protocols for residents that are fall risks, such as: -Having an extensive fall mitigation program in place including an in-house rehab partnership that have led to a reduction in the severity and frequency of falls that take place. -Current Fall Risk Assessments and resident centered fall interventions on service plans for residents identified as fall risks. Ongoing team member training on identifying changes of condition related to fall risk and resident interventions. -Policies are in place to ensure that residents who suffer multiple falls receive additional fall reduction measures. In those cases where fall mitigation measures are no longer effective, we have policies in place to aid residents/families that help determine a care setting that will best meet the residents’ fall care needs. No deficiencies cited. Exit interview conducted. A copy of this report was provided to Administrator.

Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived on 6/17/2025 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed five resident (5) and five staff files (5). All resident files contained the required paperwork. All staff files contained the required paperwork. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed. Staff training contained the required initial training. LPAs and Administrator Chad Rogers toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, dining room, hallways, and common areas. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. The disaster drill is current. The administrator's certificate is current. LPAs checked the kitchen area for the ability to prepare and store food. LPAs observed cleaning products and other toxins to be locked away. LPAs observed the area used for medication to be locked and inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detector are operational. Fire extinguisher is ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed. LPAs requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to facility.

Facility staff are not allowing resident to move freely around the facility Based on observation, record review, and statements reviewed, the department determined that there was insufficient evidence that the facility does not allow residents to move freely around the facility. Based on four (4) staff interviews, four (4) resident interviews, and department observation, residents and staff stated that residents can move freely, and that staff help residents that need assistance who would like to move around the facility; therefore, the allegations are UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Facility staff do not ensure that residents are delivered hot water throughout the facility Based on observation, record review, and statements reviewed, the department determined that there was insufficient evidence that the facility does not deliver hot water throughout the facility. Four (4) staff interviews and four (4) resident interviews state that there was never any problem with the facility hot water source; therefore, the allegations are UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Facility staff interfere with resident receiving mail in a timely manner Based on observation, record review, and statements reviewed, the department determined that there was insufficient evidence that the facility interferes with residents receiving mail in a timely manner. Four (4) staff interviews and four (4) resident interviews state that they are not aware of any problems with receiving mail on time as the residents get their mail when they want. Lastly resident’s all have individual mailboxes where staff put resident’s mail when received. Residents did not indicate any issues with receiving their mail timely; therefore, the allegations are UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.

Staff did not attend to resident in a timely manner Resident pendants are in disrepair A sample of resident call button response logs was reviewed. Based on call button logs, the typical response time for staff responding to a resident’s call alert ranges from 5–12 minutes. Residents interviewed stated they have not had issues with staff not responding to call buttons timely. Staff interviews indicated that staff usually respond to resident’s call buttons within 10-15 minutes. Staff did state that occasionally after assisting a resident, staff will forget to clear the call button request whereas documents may seem that residents are waiting for assistance longer. Based on records reviewed and interviews conducted, resident call pendant systems are operable, and staff are responding to residents in a timely manner. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Report left with facility. 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 Facility is malodorous Facility bathroom is in disrepair Based on five staff interviews (5) and four resident interviews (4) and department observation, the department observed the facility to be clean and sanitary. During department visits on 03/06/25 and 04/14/25 the department did not observe any bathrooms in despair. The facility did not observe to be malodorous including resident rooms, common areas and restrooms. All facility bathrooms were operating and sanitary. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job. Staff interviews indicated that the facility is kept clean and sanitary without any concerns; therefore, the allegation is UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not inform resident's representative of facility incident Based on documents obtained and statements reviewed, the department determined that the facility was following universal precautions for one resident with scabies. Staff is not required to notify anyone other than the resident’s family, unless there is an outbreak. Staff continued with proper hand washing and universal precautions. Therefore, the allegation is UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Residents were not provided meals in a timely manner Based on five staff interviews (5) and four resident interviews (4) and department observation of the kitchen and meal service by the department found that there was an adequate amount of food for the residents. The food appeared to look appetizing and nutritious, sanitation in the kitchen appeared appropriate, residents said food was good, and portions appeared plentiful. Food supplies in facility were adequate per requirement. Currently, there is no evidence to suggest that staff have failed to provide adequate food service or provide it in a timely manner. Therefore, the allegation is UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.

Licensee does not ensure that residents are provided with a comfortable temperature. Licensee does not ensure that the facility is kept clean and odor free Licensee does not ensure that staff follow proper sanitary food service protocols. Licensee does not ensure that food services provided to residents is adequate. Licensee did not ensure that resident received their mail. LPA and LPM conducted interviews and facility walk thru. Interviews with residents indicated resident’s have not had issues with the facility being at an uncomfortable temperature. Resident’s stated staff are consistent with cleaning their apartments as well as keeping common areas of the facility clean and sanitary. Resident’s stated they have not had issues with food service including temperature of food, quality and quantity of the food served. Lastly resident’s all have individual mailboxes where staff put resident’s mail when received. Resident’s did not indicate any issues with receiving their mail timely. During observations of the facility, LPA and LPM observed the facility clean and odor free. Facility was at a comfortable temperature during the visit. During the walk through of the facility kitchen area, LPA and LPM observed kitchen to be clean and sanitary. Food was observed to be labeled, covered and dated. Interviews with kitchen staff indicated food service staff have current food handler’s certificates. Based on interviews conducted and observation, the above allegations are found to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Questionable Death Records were reviewed regarding the death of R1. Based on documentation, R1 was on Hospice at the time of death. Records indicated R1 had a 1:1 aide (W1) present at the time of death. W1 noticed R1’s was unresponsive and contacted facility staff. Facility staff contacted Hospice. Once Hospice arrived at the facility, R1 was unresponsive and pronounced deceased. R1’s death certificate lists cause of death The above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility. 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 Licensee does not ensure that residents' call pendant systems are operable. Licensee does not ensure that staff respond to residents' requests for assistance in a timely manner. A sample of resident call button response logs was reviewed. Based on call button logs, the typical response time for staff responding to a resident’s call alert ranges from 5–12 minutes. Residents interviewed stated they have not had issues with staff not responding to call buttons timely. Staff interviews indicated that staff usually respond to resident’s call buttons within 10-15 minutes. Staff did state that occasionally after assisting a resident, staff will forget to clear the call button request whereas documents may seem that resident’s are waiting for assistance longer. Based on records reviewed and interviews conducted, resident call pendant systems are operable and staff are responding to residents in a timely manner. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Report left with facility.

Staff is sleeping during the evening hours - UNFOUNDED Based on interviews and record reviewed, it was determined that, although one person was in fact sleeping on duty on the evening shift, there were still 3 other Med Tech/Caregivers on duty and awake at the night. There is not a regulation that strictly prohibits staff sleeping. The regulations governing night supervision, 87451 (a)(2) states: "In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes." Therefore, no regulation has been violated at this time. The above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff leaves the residents soiled while in care -UNFOUNDED Staff leaves the residents unattended -UNFOUNDED Based on records reviewed and interviews, care plans are followed and implemented by staff. Department observed residents in care have care plans that are up to date and address their care needs as documented. Staff interviewed were able to demonstrate knowledge of how to implement assistance identified in the care plan. Eleven (11) staff interviews indicated that staff were providing all ADL assistance, including toileting to residents per their needs and service plan. Staff interviews indicated that staff were assisting residents for their toileting needs every 2 hours, or as needed, therefore the above allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with staff and a copy of this report was provided to the facility.

Licensing Program Analyst (LPA) Lavinia Muscan arrived on 7/1/2024 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (8) and staff files (6). All resident files contained the required paperwork. All staff files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed. Staff training contained the required initial training. LPA and Administrator Lydia Gravelyn toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, dining room, hallways, and common areas. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. The disaster drill is current. The administrator's certificate is current. LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector are operational. Fire extinguisher is ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to Administrator.

Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced on 6/3/24 to do a case management visit. LPA met with Health Services Director Stephanie Williams and explained the purpose of the visit. Department followed up on an Incident report that happened on 5/18/24. Incident report sent into the department on 5/21/24. R1 was having dinner in the dining room when R1 appeared to be choking. Staff was called and performed the Heimlich maneuver, then chest compressions. Additionally, 911 was called. R1 passed 5/18/24. LPA received all documents requested. At this time, this case in under review and department will follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.

Staff do not respond to residents' call buttons in timely manner The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During interviews, staff stated that staff respond to resident call buttons in a timely manner, however, sometimes there is a delay in response due to staff assisting other resident’s needs. During facility observation and call log review for November 2023, the department did not observe any long/extended wait times from staff to respond to resident's call button, therefore this allegation is found to be UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. 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 Staff do not ensure residents have adequate night time supervision From the record review, LPA has reviewed facility schedules, and observed that shifts were covered by multiple staff. There was no evidence to support the allegation that there was not adequate nighttime supervision. LPA learned that there were at least 2 direct care staff working on each floor during each shift. Five (5) resident interviews indicated that their care needs are met and there were no issues regarding nighttime supervisor at facility. Based on this information, LPA finds no evidence that the current staff level is insufficient. Therefore, the allegation is UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not meet resident's toileting needs. Department conducted record review, staff, and resident interviews to investigate this allegation. Nine (9) staff interviews indicated that staff were providing all ADL assistance, including toileting to residents per their needs and service plan. Staff interviews indicated that staff were assisting residents for their toileting needs every 2 hours or as needed. Five (5) resident interviews reflected that their care needs were met by staff and there were no issues to address, therefore the above allegation is UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with Administrator and a copy of this report was provided to the facility.

Staff did not seek treatment in a timely manner for resident in care Based on documents and interviews, R1 developed a rash from a cream R1 was using. The facility was in contact with R1’s doctor regarding the rash. R1’s doctor prescribed the use of a different cream. R1 has been under treatment for skin rashes for many years. R1 had an outbreak of a skin rash which was addressed with R1’s doctor timely; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff does not ensure care plan is followed for resident Based on records reviewed and interviews, care plans are followed. LPA observed residents in care have care plans that are up to date and address their care needs as documented. Staff interviewed were able to demonstrate knowledge of how to implement assistance identified in the care plan, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Facility overcharges resident for services not provided Based on records reviewed and interviews, the admission agreement for R1 is observed to be followed. LPA observed no extra charges outside of what is identified and agreed upon in R1’s care plan, which is up to date, and addresses residents’ care needs as documented, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff do not ensure effective communication is conducted with residents responsible party Based on records reviewed and interviews, it was determined that the facility was in contact with the resident’s responsible party. Emails, texts, and calls exchanged by both parties were reviewed; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview. Report left with facility.

Staff did not follow resident's diabetic diet. Department conducted interviews with residents and staff to investigate this allegation. Interviews indicated that residents were happy with dietary services at the facility and did not indicate any issues. Based on the record review for R1’s physician's reports and review of preadmission records, there are no dietary restrictions for R1, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not follow resident's care plan. Based on records reviewed and interviews, care plans are followed. LPA observed residents in care have care plans that are up to date and address their care needs as documented. Staff interviewed were able to demonstrate knowledge of how to implement assistance identified in the care plan, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not adequately supervise resulting in residents wandering into resident's room and not leaving. Based on interviews it was determined that residents in memory care that wander in other resident’s bedrooms are redirected back to their own rooms by staff. If residents continue to wander in other residents’ rooms, the doors are then locked from the outside so that residents cannot have access to other residents’ rooms. Residents' rooms have self-unlocking doors from the inside allowing residents to leave their room freely. Staff are aware of wandering in the memory care unit and address the issue as needed, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not provide resident a method of calling for assistance. Based on interviews and observation, the department finds that there are call buttons in all residents’ rooms as well as the option to wear a call button on your person. Residents and staff interviews did not indicate any issues with call light/button system at facility, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. 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 Staff did not meet resident's hygiene needs. Staff did not meet resident's dental care needs. Staff did not maintain resident's bathroom in a clean and sanitary condition. Staff did not meet resident's toileting needs. Staff did not meet resident's laundering needs. Based on interviews and observation, the department observed the facility to be clean and sanitary. During department visits on 10/11/23 and 10/18/23 the department did not find any dirty bedding. The facility did not observe to be malodorous including resident rooms, common areas and restrooms. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting and laundering needs are being met and that housekeeping, and the staff, do a great job, therefore, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with Administrator and a copy of this report was provided to the facility.

Staff gave resident another resident's medication Based on documentation reviewed and conversation with the facility representative, on 10/6/23, the facility received a medication delivered for R1 from PharMerica pharmacy. The medication bottle had R1’s name and information. The medication was for an antibiotic and not routine medications for R1. R1 was administered 4 days of the prescribed medications. R1’s responsible party (RP) was at the facility and was told the facility administered the medication to R1. R1’s RP questioned the facility why R1 was being administered an antibiotic because R1 was not prescribed the medication by their physician. Upon further investigation, the facility learned that PharMerica pharmacy labeled the medication incorrectly with R1’s information however the medication was for another individual. Once this was learned, the facility ceased administering the medication to R1 and R1’s physician was notified. R1 did not experience any side effects due to being administered this medication. Although the facility administered a medication that was not prescribed to R1, the medication was incorrectly labeled by the pharmacy therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left at facility.