Huntington Terrace.

we reserve the right to issue a new 30-Day Notice to Terminate. R7 moved out of Huntington Terrace on October 27, 2025. LPA also reviewed the Huntington Terrace notification letter dated November 6, 2025, for R7. Per letter, it states as a visitor you are required to sign in at the front desk...you refused to do so. Per letter it states, your recent visits to Huntington Terrace were disruptive and inappropriate towards other residents and staff. During the course of the of the interviews with staff, Staff 1 (S1) reported that no resident has complained about visitor being denied entrance. Per S2, R1 has not been denied visitors. S3 reported that the facility has not had an incident where R7 was denied visiting R1. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with BOM Breslin, and a copy of this report was provided to the facility.

Per Summary of Service dated August 23, 2024, under service description it states General Pest Control Maintenance and it states no activity noted. During the course of the interviews with residents, Resident 1 (R1) through R4 reported that they have never seen bedbugs. During the interviews with staff, Staff 1 (S1) through S4 reported that the facility does not have a bed bug infestation. Regarding the allegation that facility is not being maintained free of vermin , the following was revealed: During the initial visit on August 5, 2024, and subsequent visit on December 22, 2025, LPA tour the facility and did not observe vermin and/or cockroaches throughout building. During the interviews with residents, R1 through R4 reported that they have never seen vermin, cockroaches and/or insects in the facility. During the course of the interviews with staff, S2 reported that she has never seen vermin or insects in the facility. Per S2, the residents' actions influence the facility having vermin. S3 stated that no staff or resident has complained about there being vermin in the facility. Per S3, pest control did not find any cockroaches. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with BOM Breslin, and a copy of this report was provided to the facility.

Based on the review of the resident assessments, the resident assessment dated July 26, 2018 indicates R1 began receiving care at a level 5. However, LOC was reduced to a level 1 as per resident assessment dated October 25, 2022. It was noted on this assessment that the LOC was dropped after speaking to R1's wife. There was no signature obtained on this assessment. On November 22, 2022, LOC increased to a Level 3. It was noted on the assessment and narrative charting dated November 23, 2022 at 6:37pm that R1 refused to sign updated assessment. The records reveal that the signatures were not forged and was left blank. Therefore, this agency has investigated the complaint and based on the interviews which were conducted and the records that were reviewed, the following allegation, Resident's signature was forged on a document is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Executive Director Mike Marion, and a copy of this report was provided at exit. 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 The witness who had observed the interaction reported that the RN did not issue threats, but instead explained to R1 that their behavior and actions could result in an eviction due to policy violations regarding medications. The witness indicated that R1 had immediately reached out to their attorney which aligns with the narrative charting noted on July 24, 2024 at 2:29pm. The charting documented that R1's attorney agreed to facilitate R1's return of their medications. One out of three staff confirmed that R1 had prior history of not returning their medications after leaving the community. Therefore, based on the interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation, Staff threatened to evict a resident in care is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mike Marion, and a copy of this report was provided at exit.

R1’s Needs and service plan dated 8/30/2020 states R1 needs full assist with bathing, dressing and transferring. Care plan states R1 is a potential fall risk and requires two person assist. Care plan states R1 needs to be reminded to use walker and wheelchair. Facility incident reports dated 7/10/20, 7/11/20 and 1/12/21 state that resident had witnessed falls while being assisted by staff and family during transferring. Resident had two assessments conducted, one on 9/28/20 and 11/1/20. Resident Assessment Level of care remained at level 5 for both assessments. Based on staff interviews, Five staff members were interviewed regarding complaint allegations. one of five staff members (Staff 2) recalled that R1 was bed bound, difficult to transfer and needed total assist. S2 stated R1 used a wheelchair for support. Four of five staff members interviewed do not recall R1 and their level of care needed. Two of five staff interviewed (S4 & S6) stated that if a resident required a higher level of care, an assessment would be done especially if Resident needed a two person assist. Interview with witness 1 (W1) states that R1 is paralyzed and needs full assist. Based on conflicting information gathered the preponderance evidence has not been met deeming allegation resident requires a higher level of care to be UNSUBSTANTIATED meaning although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. Regarding allegation responsible party placed a camera in residents room, LPA Tirre reviewed resident 1’s (R1) file and did not observe any photo waivers or camera release in facility records. One of five staff members (S2) interviewed stated they were aware of R1 but not aware of R1 having a camera inside facility apartment. Staff interviews stated that facility policy if resident has a camera in room, resident is to have a sign posted on door indicating camera and sign a waiver/ camera release which is placed inside residents file. Staff 2 did not recall a posted sign on R1’s door. Resident 1 lived at facility between 4/1/2020 and moved out 1/16/2021. Resident is no longer residing at facility. Based on information provided, allegation responsible party placed a camera in residents room, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED. CONTINUED ON 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 Regarding the allegation Administrator is rude to residents and staff, Investigation revealed the following: Interview with Witness 1, stated that staff 1 (S1) was acting Administrator at time complaint was received and is very unprofessional and rude towards people. Per interviews with five staff members, five of five staff members do not recall S1. LPA Tirre reviewed S1’s employee records and did not observe any notes or write up’s for misconduct. According to Staff 4, S1 worked out of corporate office and assisted inside facility for temporary period of time till a new Administrator came on board. Based on information provided, allegation Administrator is rude to residents and staff, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED An exit interview was conducted with Administrator Mike Marion and a copy of report was provided

Witness called staff for assistance and R1 was transported to hospital. W2 stated that R1 returned to facility on September 28, 2021. W2 stated that R1 uses a walker and is able to complete Activities of daily living on their own. W2 stated they had no issues with level of care being provided for R1. Per Record review Facility Internal incident report dated September 24, 2021 states that R1 had a witnessed fall caused by seizure. Facility called 911 Emergency personnel. R1’s Physician’s Report dated June 17, 2020 states R1 is Ambulatory, has a diagnosis of Muscle Atrophy, receives skilled nursing services & therapy. Physician’s Report also states R1 is able to communicate needs, able to independently feed themselves, moderately independent in bathing and dressing. Per R1’S Advantage Assessment dated 6/23/20, indicates R1 is a moderate fall risk and requires stand by assistance while toileting and grooming. This department has investigated the allegation Resident sustained a fall while in care. Based on interviews and Records reviewed, investigation revealed conflicting reports. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Mike Marion and a copy of report was provided

out of 7 residents interviewed reported that the washing machines didn't work right and leaked. 5 out of 5 staff interviewed reported that there have been no issues with the washing machines and no one reported any issues to staff. It was reported that the door next to the dining room would not open and close properly and would remain open. 1 out of 7 residents reported that the door would always stay open and would not close all the way and would remain partially opened. 5 out of 5 staff reported they were unaware with any issues regarding the door next to the dining room. The Administrator reported that the door can always be used to exit but closes by itself and then is locked and cannot be opened without a key from the outside. The Maintenance Director reported that the door is functioning properly and there have been no reports about it not working properly. LPA inspected and used the door. LPA observed the door functions properly, after someone exits, it closes by itself and is locked to the outside. It was reported that the carpet in the dining room was torn and a trip hazard. The Administrator reported that the carpet was replaced in the dining room. The Administrator reported that the carpet had normal wear and tear and had been scheduled to replaced but was unaware of any trip hazards. LPA interviewed 6 out of 7 residents who reported they never noticed any tears or rips in the carpet. 5 out of 5 staff interviewed reported the carpet was old but was not a trip hazard. The maintenance director reported that flooring is replaced as needed prior to it becoming a safety hazard. LPA observed that all of the flooring in the facility during the visit was in good repair. LPA observed no deficiencies regarding the physical plant during the visit. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, The investigation into the allegation, staff were verbally harassing resident, revealed the following. It was reported that 2 kitchen staff members and the Administrator verbally harassed Resident 1 (R1). R1 reported they were yelled at and spoken to in an inappropriate manner. Staff member 1 and Staff member 2 denied the allegations. The Administrator denied the allegations. No details as to the time and date of the incident were provided. 5 out of 5 staff members interviewed reported they have never witnessed any staff speaking inappropriately to any resident. 7 out of 7 residents interviewed reported they have never witnessed or been spoken to in an inappropriate manner by staff. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, 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 The investigation into the allegation, facility does not provide a safe environment for residents, revealed the following. It was reported that the door by the kitchen, which leads to the parking lot is left open at night and people who do not live at the facility come into the facility and pose a threat to residents in care. 5 out of 5 staff interviewed reported the door is always closed and no one who isn't a resident has come into the facility though the door. 1 out of 7 residents interviewed reported that they saw someone who did not live at the facility come in through the door at night. No specific details were provided in this report. 6 out of 7 residents reported they have never seen anyone other than residents use the door. The Administrator reported that the door is working properly and a key is required to open the door from the outside. The Administrator reported that all night staff are aware and have been trained that all doors are required to closed and locked to the outside, except during normal business hours. LPA observed the door functions properly, after someone exits, it closes by itself and is locked to the outside .A review of incident reports from the facility for the months of August 2025 and September 2025 do not show any incidents that are related to the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with the Administrator and a copy of the report provided.

A review of the eviction notice shows the eviction notice had all the information required by Title 22, which governs all facilities licensed by the Agency. The eviction notice is lawful. During the investigation on September 4, 2025, the facility rescinded the eviction notice and provided R1 with a letter informing them of their decision. R1 verified they received and read the rescission letter. R1 is no longer required to leave the facility. Based on the evidence gathered the allegation, unlawful eviction, is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with the Administrator and a copy of the report was provided.

Licensing Program Analyst (LPA) Michael Tea made an unannounced visit for the purpose of conducting a health and safety check. LPA was greeted and granted entry by staff. LPA met with Executive Director (ED) Mike Marion and discussed the purpose of the visit. During today's visit LPA followed up on a death report for Resident 1 (R1) dated August 20, 2025, received by CCLD on August 22, 2025. LPA toured the facility and conducted a health and safety check on all residents in care. LPA observed no health and safety issues. LPA obtained pertinent documentation such as Resident Face sheet, Identification and Emergency Information, Medical Assessment, Preplacement Appraisal, Release of Medical Consent, POLST, Facility Resident Assessment, Needs and Service Plans, R1's Narrative Charting Notes and MAR. LPA filled out the questionable death report. An exit interview was conducted with ED Marion and a copy of this report along with a list of confidential names was left with the facility.

On July 21, 2025, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced annual inspection of the facility. Upon arrival, LPA Haddadin was greeted by the Executive Director (ED), Mike Marion, who granted entry and was advised of the purpose of the visit. Together, they toured the interior and exterior of the three-story building. The facility is licensed for thirty (30) ambulatory residents and one hundred fifty-five (155) non-ambulatory residents, which includes fifteen (15) bedridden residents. The facility has an approved hospice waiver for thirty (30) residents. The total capacity is 185 residents, and the census at the time of inspection was 166. During the visit, residents were observed in the dining room enjoying breakfast, while others participated in scheduled physical activities or rested in their rooms. Eight resident rooms were chosen randomly for inspection and were found to be furnished with a bed, a chair, and clean linens. The rooms also provided adequate storage space and were free of tripping hazards. Exterior portions of the facility, including the courtyards, were well-maintained. Furnishings were in good repair, pathways were clear of hazards, and the grounds appeared safe and inviting with a shaded seating area. Eleven fire extinguishers were checked and observed to be fully charged, with the indicators in the green zone. The hot water temperature in the randomly selected rooms was measured between 113.8 ∘ F and 115.5 ∘ F, meeting regulatory requirements. The facility maintains sufficient food supplies, including at least a two-day supply of perishable items and a seven-day supply of nonperishables. The kitchen was observed to be in good repair, and all major appliances were operational. Cleaning supplies were stored securely and were inaccessible to residents. All medications are kept locked in the medication room on the third floor, inaccessible to residents in care. A review of residents' files showed no discrepancies. Staff files were complete, each containing the required documentation. 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 Records further confirmed that the facility conducted its annual emergency drill on June 25, 2025. Based on today's visit and observations, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Mr. Marion, and a copy of this report was provided to him.

Licensing Program Analysts (LPAs) Eboni Bentley and Jessica Cho arrived at the facility unannounced to deliver amended complaint investigation findings for Complaint Control No 22-AS-20250703124044 for visit date July 8, 2025 from 8am-1:50pm . LPAs were greeted and granted entry after stating the purpose of the visit to Executive Director (ED) Mike Marion. An exit interview was conducted with Executive Director Mike Marion, and a copy of this report including the amended complaint investigation report were provided at the end of the visit.

LPAs were given a tour of the kitchen by Dining Supervisor Kathy Ofeguede and observed ample amount of perishables and non-perishable food items. LPAs observed a variety of proteins such as chicken, beef, pork, fish which include salmon, tilapia, shrimp, and etc. Based on the interviews, sixteen out of the sixteen residents and three out of the three staff indicated that residents are served three fresh and nutritious meals a day, alternative options are available upon request, the menu is typically followed, meals meet the food groups with a variety of proteins served, and snacks are available in the Bistro throughout the day. Based on the review of weekly and daily menus, residents are provided with a variety of adequate meals with alternative options available upon request. Per the menus for the weeks of June 22nd, June 29th, and July 6, 2025, salmon is typically served once a week on Fridays, however there is a second option available for lunch and dinner as well as the daily menu alternatives. Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegation: Staff are not providing adequate food service to residents, is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mike Mario and Business Office Manager Timarie Morrissey, and a copy of this report was provided at the end of the visit.

On February 24, 2025 Licensing Program Analyst’s (LPAs) Jenifer Tirre and Edward Kim conducted an unannounced visit for the purpose of conducting a required annual visit using the CARE Inspection Tool. LPA’s were greeted by staff and granted entry after stating the purpose of the visit. Administrator (AD) Mike Marion was present to assist with the facility inspection on today's date. The facility is licensed for thirty (30) Ambulatory residents, One hundred fifty five (155) Non Ambulatory which 15 bedridden with approved hospice waiver for thirty (30) residents. Currently, there are twelve (12) Hospice residents present during today’s visit. Facility is a three story building with 155 units combined in both Assisted Living and Memory Care. At around 8:15 AM, LPA’s Tirre and Kim conducted a tour of the physical plant accompanied by Director of sales Susan Peterson, and the following was observed: Facility has an enclosed pool located in outside patio area. Rooms which were inspected observed to be furnished Beds and bedding supplies were in operational condition, lighting was provided, and storage for the Resident’s personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 108.5 to 115.5 degrees F. A comfortable temperature of 70 degrees F. was maintained in the facility. Residents were observed relaxing in common areas, eating on the dining room, and relaxing in bistro as well as relaxing in bedrooms. Memory care residents were observed engaged in group exercise activities. The kitchen was inspected, and facility has sufficient perishable and non-perishable foods as well as supply of emergency food and water. Storage areas for sharps objects and cleaning supplies were stored and not accessible to residents. Facility has multiple fire extinguishers. During today’s visit Ten (10) fire extinguishers were observed to be fully charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA’s observed the records are in compliance. CONTINUED ON 809C 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 During the visit, LPA’s observed the facility's infection control practices. LPA’s observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. A working landline phone was operational. Facility has operating smoke detectors and audible alarms which LPA's observed Last fire inspection paperwork was completed by Fire Safety Service, The last fire drill was conducted on January 28, 2025. The facility has current liability insurance on file effective 7/1/2024 – 7/1/2025. LPA’s observed four evacuation chairs located on top of third story stairwells. During today’s visit a review of Seventeen (17) residents (R1-R17) service files and Ten staff (S1-S10) personnel files revealed to be complete. The facility has the current administrator's certification on file for Michael Marion Expiration 9/12/2025. No deficiencies during this inspection visit. An exit interview was conducted with Executive Director Mike Marion, and a copy of the report was provided.

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced case management visit to Huntington Terrace. LPA was greeted, granted entry, and explained the reason for the visit. LPA met with Business Office Manager Timarie Morrisey. The purpose of today's visit was to conduct a Case Management visit to discuss self reported incident that was sent to the Orange County Adult and Senior Care Regional Office on September 30, 2024 and to gather information and documents. On today's visit LPA Tirre discussed the incident regarding Resident 1 (R1) with Business Office Manager Timarie Morrisey. LPA Tirre obtained records related to incident such as bank statements, copy of deposit, facility staff roster, facility resident roster, and Resident physicians report. LPA conducted interviews with Business Office Manager and R1. No deficiencies observed during visit. A exit interview was conducted with staff representative and a copy of report was provided.

inappropriately from any staff at the facility. Interview with 3 of 3 staff indicated that staff 1 (S1) and staff (S2) went to R1’s cottage to retrieve medication and R1 was upset and not cooperating. S2 indicated that they were there to be a second pair of eyes and we observant to the interaction between R1 and staff. Staff indicated that R1 had been out of the community and upon return did not return his medication to staff. S2 stated that R1 was very upset and was not cooperating with staff and staff was simply trying to retrieve the medication. Record review revealed that R1 is on med management with the facility. It is alleged staff do not comply with an infection control practice. Interview with staff (S3) indicated that facility had 15 residents who tested with covid in early July and by July 29, 2024, all the 15 were cleared. S3 stated that they called The Public Health Department and informed them of the positive test and were informed to only test residents that are exhibiting symptoms as well as to close the dinning hall for precaution. Therefore, mass testing was not required. Per directive from public health dining to resume operations as usual on July 27, 2024. Facility was following protocol for Department of Social Services as well as the Department of Public Health. We were also told that it is considered an out break when there is 20% of the census positives. Which in this case it was not because 20% would be about 32-33 residents. It is alleged that staff behavior is preventing a resident from sleeping. Interview with R1 did not give any indications about being disturbed at night or not being able to sleep. Interview with 8 of 8 residents indicated that they don’t hear any noise or disruption that may prevent them from sleeping. Resident also indicated that it is rare that staff come to their bedroom late at night. Interview with S3 stated that R1 has always been a night owl since they move in the facility and has always had a hard time sleeping till late at night. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.

The end of day reports are provided by Med Tech’s to communicate with care giving team of updates. Record review reveals that facility sends out fax confirmations of incident reports submitted to Licensing Agency and Primary Care Providers of incidents with residents. LPA reviewed recent reports and fax confirmations documented. Based on staff interviews investigation revealed that when an incident occurs with a resident, facility staff assess situation, if serious condition or at request of resident; resident may be sent out to hospital, family are contacted in conjunction with incident, Care Providers are notified as well as Licensing Agency. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director and copy of this report along with appeal rights was left at facility.

Based off interviews and statements conducted with staff, six of six staff state they try to meet the needs of their residents as best as they can, respond to calls within 10 to 15 minutes and has sufficient staff on site. Interviews revealed that during 2020 to 2021, facility used staffing agencies to help fill in shifts. Interviews with Four of Four staff responsible for medications stated resident 1 received medication as prescribed however mentioned that resident 1 medication times would vary depending on resident’s schedule. Interviews with staff revealed resolution in Resident 1’s medication schedule. Interview with Resident 1 revealed that Resident 1 stated they have no issues with staffing and stated staff assist with ADL’S such as showering, toileting, medication and transporting to facility dining area. Interview revealed that resident confirms if they have an issue with facility, they bring attention to issue. Resident confirms they like living at facility and feels safe in facilities care. During investigation, LPA reviewed documentation and investigation revealed the following: Facility Assessment records dated from 3/29/2020 to 11/28/2023 revealed that Resident 1 has daily status checks 4 times per shift, 12 times a day. Facility Assessments are updated every 6 months. Hospice Records revealed that Resident 1 received weekly showering and wound care from 9/16/2020 to 12/23/2020. Facility notification revealed discontinued Hospice care for Resident 1 on 1/29/2021. This department has investigated these allegations and based on LPA’s observations, and interviews which were conducted investigation revealed conflicting reports. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegations are all deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator and a copy of report along with LIC 811 Confidential Names List was provided.

On May 24, 2020 R1 was transported back to Huntington Terrace from Anaheim Global. Upon arrival, R1 was noted to be lethargic and weak which was consistent with progress report updates received in the days prior. The staff and R1’s responsible party believed at the time R1 to be over medicated. Huntington Terrace staff reported R1’s condition to an approved Doctor and on May 25, 2020 received orders to cut R1’s medication dose in half. On May 26, 2020 staff noticed a change in R1’s condition and informed R1’s responsible party and approved Doctor. R1’s approved Doctor recommended R1 be sent out to the hospital. Staff reported they offered to call 9-1-1 but R1’s responsible party declined, instead stating they would take R1 to the hospital. Interviews conducted with R1’s responsible party disputed staff’s reports, stating that facility staff offered to have R1 assessed by the facility doctor a few days later on May 28, 2020 instead of taking R1 to the hospital. R1’s responsible party declined and took R1 to the hospital after consulting with a family member in the medical field. R1’s preplacement appraisal completed on May 24, 2020 notes R1 was able to bear weight using a front wheel walker with assistance. R1 was admitted to the hospital on May 26, 23 at 5:13PM and was diagnosed with dysphagia, Lacunar Stroke and Right Hemiparesis. The medical records reviewed notes that R1’s responsible party told hospital staff R1 was lethargic and weak upon being picked up from Geriatric Psych. Hospital records reviewed further notes that R1’s responsible party informed hospital staff R1 called them on May 23, 2020 and reported having right sided weakness, a day prior to R1 being transported back to Huntington Terrace. R1 was further diagnosed with an Acute kidney injury due to dehydration which was noted to be resolved as of May 28, 2020 with IV hydration. Due to the dysphagia R1 was ordered to have a feeding tube and required pureed diet and thickened liquids. Findings from R1’s chest X-Ray notes chronic lung changes compatible with previous granulomatous. Per facility records, R1 was listed as participating in the facility’s meal club due to requiring assistance with feeding and having a special diet upon return on May 24, 2020. Facility meal attendance tracking records note that R1 refused to eat dinner the night of May 24, 2020. The following day R1 was noted to eat Lunch but did not eat dinner. A day later, records show R1 ate all three meals in their room. Although facility staff did not immediately call 9-1-1, interviews and records obtained confirmed staff were communicating with R1’s approved Doctor regarding R1’s condition and were following physician orders. It remains unclear at this time if the actions taken by the facility were sufficient to determine if timely services were sought. CONTINUED ON 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 Furthermore, although R1 was refusing meals, documentation observed and interviews conducted could not corroborate if R1’s dietary needs were not being met due to R1’s choice to refuse services or facility staff neglect. Therefore, based on a records reviewed and interviews conducted, the allegations that Staff did not seek medical attention for resident in a timely manner and Staff did not ensure that resident's dietary needs were met was determined to be Unsubstantiated. Although the allegations may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was provided at the time of exit.