Sagebrook Senior Living at San Francisco

On 03/27/26 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced case management visit. LPA met with Administrator, Peter Nixdorff, and explained the purpose of the visit. LPA conducted an inspection to verify receipt of the Decision and Order and to ensure that the named individual is no longer employed at or associated with the facility, effective as of the case management visit. LPA toured the facility and reviewed and collected relevant documentation. The named individual was not present on the premises. Report is reviewed and copy is provided .

On 3/11/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a proof of correction(POC) visit. LPA Calandra was greeted by Peter Nixdorff, Executive Director and explained the purpose of the visit. On 3/11/2026, the Licensee was cited for a violation of Title 22, California Code of Regulations(CCR) 87411: Personnel Requirements-General regarding a client who was able to elope from the facility as S1 had not started their shift. Deficiency has been cleared. A proof of correction letter was delivered with this report to the facility representative and an exit interview was conducted.

On 1/5/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Proof of Correction(POC) visit in regards to citations issued during the Annual Inspection on 12/15/2025. LPA Calandra was greeted by Juvy Valera, Concierge and explained the purpose of the visit. On 12/15/2025, the Licensee was cited for a violation of Health and Safety Code 1569.32 Spot Inspections which states that "any duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, this chapter." At time of inspection, Licensee d id not ensure that resident and personnel files were accessible and could be reviewed by the LPA for several hours. During POC visit, LPA observed that a second key has been made to the business office where files are kept and is accessible to the Concierge. Deficiency cleared during visit. On 12/15/2025, the Licensee was also cited for a violation of Health and Safety Code 1569.618: Administration and Management of Residential Care Facilities; substituted qualifications; employee scheduling as they did not ensure that at least one staff member per shift on duty and on premises with active CPR and First Aid training. During POC visit, LPA reviewed staff schedule and CPR and First Aid training certificates and found that at least one staff member per shift has active CPR and First Aid training. Deficiency cleared during visit. No deficiencies cited during today's visit. An exit interview was conducted and a copy of the report was provided.

On 9/24/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit in regards to an incident report received by the Department on 9/19/2025 in which a resident eloped while in the community. LPA was greeted by Peter Nixdorff, Executive Director and explained the purpose of the visit. LPA toured the physical plant. All exit doors and door alarms were observed to be fully operational. In addition, LPA conducted interviews. Based on interviews, R1 was attending a medical appointment under the supervision of R1's responsible party when R1 was able to elope. Peter Nixdorff, Executive Director called the police, local hospitals, and other locations to locate the resident but R1 has not been found at the time of the visit. No deficiencies cited during today's visit. An exit interview was conducted. This report reviewed with the Executive Director and a copy of the report provided to facility representative.

On 4/10/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following up on a facility reported incident involving resident (R1). Incident indicates R1 leaving the facility unassisted. LPA interviewed staff and reviewed resident records. R1 was newly admitted to the facility and was in the process of transitioning to supervised care. R1 had left the facility through a kitchen exit not operated by caregivers. R1 was safely located and returned to the facility with no injuries or change of condition. Executive Director had implemented in-service training, updated signeage on exits/elevators and held multiple care conferences with R1 and R1's responsible party for updated care. R1 has since relocated and residing elsewhere. LPA found that the facility responded appropriately to the incident to ensure prevention and discussed further implementation of staff supervision with Executive Director. Technical violation issued during today's visit.

Upon inspection of bedrooms 300 and 304, LPA found that the facility is still undergoing repairs. However, LPA observed residents' rooms to be equipped with personal space heaters and additional blankets. LPA was able to interview resident (R1) located in room 300. R1 did not have any concerns or report being cold and stated that they felt fine. R1 was observed on their bed and showed LPA the additional blankets they were using. R1's space heater was off during the inspection but was tested and in working order. In addition both rooms (300 and 304) did not appear to be cold or at a discomforting temperature. LPA contacted San Francisco Ombudsman Officer, (O1) who also confirmed that they had conducted a facility inspection in response to the allegations. O1 indicated that the facility had provided additional blankets and space heaters for resident bedroom still in need of services. O1 also stated that during their visit, they were not able to conduct/determine a temperature reading due to no thermostat. Lastly, O1 reported the facility to have responded appropriately and in a timely manner. Complaint alleges facility is in disrepair after facility heating system had become damaged. Based upon interviews with staff (S1,S2) it was determined that the facility heating system had become damaged due to the boiler flooding and effecting the heaters. The facility became aware on 11/17/2024 and began repair requests immediately. Interview with Maintenance Director (S2) indicated that service repairs were submitted the following day. LPA was provided the invoice for the first repair service to the boiler. In addition, residents who's bedrooms were affected and had no working heater, were provided additional blankets and portable space heaters to accommodate while the facility repairs were in place. LPA was informed by Maintenance Director (S2) that the bedrooms 300, 301, 302 and 304 had been affected by the heating system damages. Upon inspection of bedrooms, LPA found that the heaters in rooms 301 and 302 had been restored to working condition with heaters observed to be on and the bedrooms warm and comfortable. Upon inspection of bedrooms 300 and 304, LPA found that the facility is still undergoing repairs with the remaining two bedroom heaters, but had provided appropriate accommodations. Although the facility had undergone damages to the heating system, LPA found that the facility had responded appropriately and timely in order to have the system restored. Due to contradicting information gathered during the course of the investigation the allegation is found to be unsubstantiated. A finding that the complaint allegations, staff did not maintain a comfortable temperature for residents in care and facility is in disrepair are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited.

According to the Memory Care Director, there are 2 caregivers and 1 Medication Technician (Med Tech) on the unit for the AM and PM shifts and 2 caregivers and 1 Med Tech on the night shift. The Memory Care Director stated that there should always be a staff in the dining room to supervise the residents and if the residents needed to be change, and/or wanted to go back to their rooms, the caregivers would provide the assistance while the Med Tech stayed in the dining room. LPAs interviewed the facility staff members who stated there is always someone providing supervision in the dining room. They also stated that they would bring the residents to the bathroom and/or back to their rooms after the meals but if the residents needed to go to the bathroom or to be changed prior to their meals, they would assist the residents. Furthermore, they stated that some residents would walk back and forth from the dining room to the hallway and back and sometimes they would redirect them to stay in the dining room for their meals. LPA interviewed R1 who slipped out of the wheelchair while getting some fresh air and R1 stated that it was an accident and several staff members helped and responded to the incident right away. R1 also stated that staff members were responsive but sometimes the response time took a longer because they were busy. LPAs interviewed R2 who stated that due to his/her vision problem, it would be a big challenge in the morning if he/she was assigned to a caregiver who did not know the routines such as an agency staff. During the interview with R2, LPAs attempted to obtain additional details regarding to being isolated in the room as the reporting party reported, however, R2 did not want to provide any information. LPAs interviewed the Resident Service Director who was aware of R2's health condition and stated that most of the time, R2 is being assigned to a regular caregiver. However, when there were sick calls, they had to readjust their schedule and get someone from the agency and resulted R2 not being assigned to a regular staff. Based on documents provided, LPA observed R2 required additional assistance and the Resident Service Director is meeting with R2 on a regular basis to ensure R2's needs are being met. LPA interviewed other residents and they stated that they liked the facility, and staff members were caring and assisting them with their needs. After the investigation, this allegation is deemed to be unsubstantiated. Although the above investigations 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 allegation is UNSUBSTANTIATED. This report is reviewed and discussed with the Director.

On February 23, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a case management health and safety inspection. LPA Calandra met with Jennine Chan, Assistant Executive Director and explained the purpose of his visit. During the visit, LPA Calandra toured the physical plant. LPA Calandra toured the facility kitchen, living and dining room, and 3 floors. LPA Calandra observed that the facility had sufficient perishable and non-perishables on hand and the community was observed to be in good physical condition. LPA Calandra also spoke with Stephanie Hall, Executive Director via the phone. LPA Calandra interviewed 2 residents and 2 staff. No deficiencies were cited during today's visit. The report was reviewed with Jennine Chan, Assistant Executive Director and a copy was emailed to Jennine. LPA confirmed receipt of email prior to leaving the facility.

On January 31, 2024 at 8:17 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to continue the Annual 1-year required inspection. LPA Calandra was greeted by Juvy Valera, Concierge at the door and explained the purpose of his visit. Faimafili Igafo, Executive Director joined the visit later. LPA Calandra interviewed 3 staff and 4 residents. LPA Calandra reviewed 5 resident records which were observed to be complete and 5 staff records which were all observed to be complete. No deficiencies were cited during today's visit. The report was reviewed with Faimafili Igafo, Executive Director and a copy left at the facility.

On January 31, 2024, Licensing Program Analyst(LPA) John Calandra, arrived at the facility at 8:16 AM to conduct a Plan of Correction(POC) visit. LPA Calandra met with Fili Igafo, Executive Director and explained the purpose of his visit. No deficiencies were cited during today's visit. The report and POC clearance letter was reviewed with Fili Howard, Executive Director and a copy left at the facility.

In addition, the administrator stated that on the day of the discharge, facility provided a caregiver to escort R1 home where R1's friend was present. LPA spoke to R1's case manager who validated that the facility was instructed to discharge R1 home per R1's directive. After the investigation, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis. This report is reviewed and discussed with the sales director A copy is provided.

On 5/3/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility. On 5/1/2023, facility reported resident #1 (R1) was admitted to a skilled nursing facility on 1/20/2023 and returned on 4/26/2023 at 5PM. On 4/27/2023 at 1:30AM, a caregiver provided care to R1 and at 2:30AM, the same caregiver witnessed R1 to be unresponsive. Caregiver notified a med tech who observed R1 to be pale with no pulse then proceeded with calling 911. At 3:10AM, R1 was pronounced by 911. At 10AM, R1 was picked up by Coroner and taken to the mortuary. During today's visit, LPA requested for documents; LIC 602, reappraisal, service plan, hospital records and facility documentation to be submitted to CCL by 5/4/2023. No deficiency cited today. This report is discussed and reviewed with sales director.

Concerning to R1 did not get the food items as ordered, the administrator stated that upon R1's admission, R1 selected the items from the weekly menu for breakfast, lunch, and dinner and when R1 did not get items as ordered, staff went to the kitchen and got it. The administrator also stated that since the mistakes were reported, the management team such as the resident care director, the dining service director and the administrator have met with R1 several times to improve R1's dining experience. In addition, the administrator has implemented a new system to improve tray/meal accuracy. According to the dining service director, he/she has met with R1 multiple times concerning food preferences and accuracy. He/she has reminded kitchen staff to check food accuracy before it leaves the kitchen and in-serviced them on improving communication. The dining service director also stated that since the new system that was implemented by the administrator, tray/meal accuracy has improved for R1. In addition, the facility staff brought R1 additional snacks that R1 did not order to ensure R1 has enough of it but R1 mistaken it as staff did not follow his/her food preferences. LPA interviewed facility staff who stated that when R1 did not get the food items as ordered, they would go to the kitchen and get it for R1 but that only happened when R1 was first admitted to the facility. LPA interviewed 4 residents and all of them reported that the facility serves good food, the dining experience is great and there are snacks available. Based on observation, interviews and record reviews during the course of the investigation this allegation is deemed to be unsubstantiated. However during the investigation visit, LPA reviewed R1's selective menu and under beverages, R1 selected orange juice but R1 was served apple juice. This observation will be documented on an advisory notes (LIC 9102 Technical Assistance). Although the above allegation 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 allegation is UNSUBSTANTIATED.

On 1/5/23, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Resident Care Director, Jennine Chan. LPA explained the purpose of the visit and LPA was screened at the front entrance. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies, PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels; COVID-19 signs are observed to be posted through-out the facility; residents have their own rooms except for couples; hand washing instruction is posted by the hand washing stations; hand sanitizers are observed at varies locations within the facility. Residents and staff are being screened for COVID-19 on a daily basis and visitors when they entered the facility. During the tour, LPA observed both medication rooms were open with staff members present and staff reported that the rooms are locked at all times when no one is there. First aide kits are observed to be equipped and stored in the medication rooms. A comfortable temperature is maintained, lighting is sufficient for comfort. The facility appeared to be cleaned and tidy; dinning rooms are observed to be spacious, comfortable and furniture is spaced out. 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 today's visit, LPA Han requested for the following documents to be submitted to CCL by 1/10/23: -LIC308 Designation of Administrative Responsibility -LIC500 Personnel Report -Administrator Certificate No deficiency cited today. This report is reviewed and discussed with the Resident Care Director, Jennine Chan. A copy is provided.

On 7/19/2022 Licensing Program Analyst (LPA) Murial Han conducted an unannounced follow-up visit to deliver the outcome from the case management visit on 6/20/22 concerning an incident that was reported by the facility on June 3, 2022. On June 3, 2022, CCL received a LIC624 (Unusual Incident/Injury Report) from the facility regarding resident #1 (R1) was delivering mail to resident #2 (R2) and was told by R2 not to touch the mail that does not belong to R1. R1 appeared upset, left the facility and went to a nearby store where R1 was witnessed by a bystander performing an unusual activity which triggered the bystander to call 911. In addition, the bystander also called the facility to confirm R1 was a resident at the facility. Based on the documents provided by the facility, R1 is able to leave the facility unassisted, and according to staff, R1 enjoys to walk outside of the facility and returns when R1 is ready. Concerning to resident's mail, staff stated that facility has a system to ensure mails are delivered to the residents on the day as they arrive. However, the mails were delivered late on the day prior to the incident and they were left on the receptionist desk. On the next morning, R1 got hold of them, took the mails that belonged to R2 and delivered them to R2 as a nice gesture but it was not appreciated by R2 which made R1 upset and left the facility. The staff also reported that there was no alteration between R1 and R2. Based on record review and interviews, no deficient cited. This report is reviewed and discussed with the administrator. A copy is provided.

On June 20, 2022, Licensing Program Analyst (LPA) Murial Han conducted an case management visit regarding an incident that was reported to CCL. LPA met administrator and explained the purpose of the visit. On June 3, 2022, CCL received a LIC624 (Unusual Incident/Injury Report) from the facility regarding resident #1 was delivering mail to resident #2 and was told by resident #2 not to touch the mail that does not belong to resident #1. Resident #1 appeared upset, left the facility and went to a nearby store where resident #1 was witnessed by a bystander performing an unusual activity which triggered the bystander to call 911. In addition, the bystander also called the facility to confirm resident #1 was a resident at the facility. After the facility was notified by the bystander of a potential resident, facility staff went to the nearby store and confirmed that it was resident #1. Resident #1 returned to the facility later on that same day after the hospital stay. During today's visit, LPA interviewed the administrator and collected some documents and addition documents- Care Plans, and medical records will be provided by 6/21/22. This incident requires further follow-up. This report is reviewed and discussed with the administrator. A copy is provided.

On 11/3/21 Licensing Program Analyst (LPA) Murial Han conducted an unannounced follow-up visit to deliver the investigation outcome concerning an incident that was reported to the Department on 9/20/2021 concerning Staff 1 (S1) alleged Staff #2 (S2) strongly pulled Resident #1 (R1)'s ponytail in the dinning room when asking R1 to sit down on the couch. During the initial visit on 9/22/2021, LPA Han requested for documents, interviewed staff. reviewed records and observed R1 who appeared to be calmed and was lying down on the couch watching TV with other residents. R1 was not able to recall the incident. LPA Han interviewed S2 who denied of pulling R1's ponytail and stated that he/she tapped R1's shoulder as R1 was leaving the dining to redirect R1 back into the dinning room to watch TV where S2 can continue to provide supervision. LPA Han interviewed the Clinical Director and the Administrator regarding to the facility's investigation process. The facility followed their investigation protocols and determined that the allegation to be unsubstantiated, however as an abuse prevention, the facility has provided an in-service to staff on "Elder Abuse Reporting". After the investigation, no deficient cited.

On 7/27/2021, the facility reported that a caregiver had been removed from the facility after it was found to have engaged in an inappropriate contact with a resident. The Department made a case management visit regarding the incident on 7/28/2021 and initiated an investigation. On 11/3/2021, Licensing Program Analyst (LPA) Murial Han conducted a follow-up to deliver the findings of the investigation. The Department determined that on 7/26/2021, a staff member (S1) indicated to another staff (S2) intentions to give a resident (R1) a shower. After a few minutes, S2 went to assists S1 and found S1 with pants down and in underwear within the bathroom and in the presence of R1. S1 denied a sexual encounter but acknowledged an emotional relationship with R1; therefore, the S1 was removed from the facility immediately. During the investigation, the Department collected documentation and conducted interviews. S1 denies engaging in sexual contact with R1 but acknowledges a relationship with the resident. R1 is unable to communicate and unable to acknowledge any relationship, and given R1’s health condition, unable to consent. No other staff acknowledged awareness of S1’s claimed relationship with R1. Based on interviews conducted, there is preponderance evidence to show that S1 engaged in inimical behavior and engaged in inappropriate contact with a resident in care. Therefore, facility staff violated the resident’s personal rights. Appeal rights and penalty assessments have been explained to Facility Representative, and the following Type A deficiency is cited based on Title 22, Division 6 of California Code of Regulations.

On 9/22/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow-up on an incident reports/ SOC 341 that was reported by the facility. LPA Han met with the Clinical Director, Jennine Chan and explained the purpose of the visit. The facility reported that Staff 1 (S1) alleged Staff 2 (S2) strongly pulled Resident 1 (R1)'s ponytail in the dining room when asking her to sitting down on the couch. The Clinical Director conducted a skin assessment for R1 and no injuries were noted. During today's visit, LPA interviewed staff, observed R1 and requested for documents. This incident requires further investigation. This report is discussed and reviewed with the Clinical Director. A copy is provided.

On 9/142021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings from a Case Management visit on 8/23/2021. LPA Han met with the Executive Director, Fili Howard and explained the purpose of the visit. The incident happened on 8/17/2021 around breakfast time, when the Medication Technician was preparing medication in the dining room, he/she heard a loud noise and witnessed that R1's right arm was extended upward in a swinging motion and R2 was on the floor. The staff reported that R2 has a tendency of grabbing other resident's foods so when R1 saw R2 attempted to grab R3's food, R1 probably pushed R2. During LPA's visit on 8/23/2021, LPA observed R1 and R3 to be calmed in the dining room and awaiting for their lunch. R1 was sitting at a table and having conversation with another resident. LPA observed several staff members in the room assisting the residents. LPA interviewed R2 and R3 regarding the incident and both of them couldn't remember anything about it. LPA interviewed three caregivers who were in the dining during the incident and they stated did not witness the incident as they were assisting other residents with their meals but they looked up as they heard a loud noise and witnessed R2 on the floor. They reported that R2 has a tendency of grabbing other resident's food and they were trained on how to distract R2 from doing that. After the incident, the facility has updated R1's care plan including medication review to address the recent aggressive behavior. R2 was transferred to the acute hospital for the fall and the facility requested the hospital to perform a medication review prior to discharge due to the recent behaviors. R2 has returned to the facility and the staff members reported that R2 seemed to be calm and comfortable. There is no further incidents. No deficiency is cited today. This report is reviewed, discussed with the Administrator, Fili Howard, a copy is provided.

On 8/23/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow-up on an incident reports/ SOC 341 that was reported by the facility. LPA Han met with the Executive Director, Fili Howard and explained the purpose of the visit. The incident happened 8/17/2021 around breakfast time, when the Medication Technician who was preparing medication in the dining room, he/she heard a loud and witnessed that R1's right arm was extended upward in a swinging motion and R2 was on the floor. The staff reported that R2 has a tendency of grabbing other resident's foods and R1 was trying to stop R2 from grabbing R3's food. During the visit, LPA interviewed the Executive Director, the staff members who were in the dining room during the incident, and the residents who were involved in the incident. In addition, LPA observed the dining room area and requested for additional documentation for the residents who were involved. This incident requires further investigation. This report was reviewed and discussed with the Executive Director and a copy is provided.

On 07/28/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted a Case Management visit at the facility with Executive Director (ED) Angela Boucher Tunin, regarding an Incident Report received by the Community Care Licensing Division on 7/27/21. The incident involves a female resident (R1) and a male caregiver (C1). LPA Filouane reviewed the information reported on the Incident Report. The facility's investigation is currently ongoing. In an interview with the ED, LPA Filouane clarified the information reported on the Incident Report. The incident occurred on 07/26/21, when another caregiver (C2) had entered the Memory Care unit of the facility. It is reported in the Incident Report and in an interview with the ED that C2 opened the restroom door and witnessed C1 with their back turned, hands raised, and their trousers down to their knees with their underpants still raised, standing close towards R1. R1 was leaning against the restroom sink with their hands on their side. R1 wore only a bathrobe. It is reported that after C2 witnessed that C1 was undressed with a resident, C2 had went to inform a Medical Technician on duty. The Medical Technician then arrived at the restroom in the Memory Care unit and witnessed the resident unclothed and C1 showering the resident. The Medical Technician reported the incident to the Executive Director, who instructed C1 to leave the facility pending investigation. The Executive Director states that on the same day of 07/26/21, after the ED had instructed C1 to leave the facility, C1 was found in a resident's closed room with R1 and another resident. The Executive Director made their way to the room and estimates that C1 was in the room with R1 and another resident for less ten minutes. According to the ED, the ED asked what C1 was doing in the room, and C1 stated they were telling R1 that they were leaving. San Francisco Police Department arrived at the facility on 07/26/21 and interviewed the resident. Facility management interviewed the caregiver and Medical Technician. LPA requested physician reports of two residents, documentation of facility interviews with staff members, and will contact SFPD for the police report and R1's hospital visit results. Exit interview conducted with Executive Director. This report will be emailed to the Executive Director.

On 6/ 23 /2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow-up on two incident reports/ SOC 341 reports that were reported by the facility. LPA Han met with the Executive Director, Angela Boucher- Turin and explained the purpose of the visit. The facility has reported two incidents involving resident to resident altercations during meal services in the dining room: First Incident: on 6/5/2021, Resident 1 (R1) wanted additional cookies and attempted to grabbed Resident 2 (R2)'s cookies that caused R2 to stand-up from his table and when Resident 3 (R3) saw R2 stood up, he/she thought R2 was going to hurt R1 so he/she pushed R2 and R2 sustained some injuries. Second Incident: on 6/13/2021, R1 was grabbing food from Resident 4 (R4) that caused R4 punching R1's face, stumbled backwards and fell. Staff reported that there was no injuries noted to both residents. Since the first incident, the facility has increased supervision for R1, reviewed and updated R1's care plan, and provided one on one feeding assistance. Furthermore, the facility has consulted with their consulting group regarding R1's behaviors as R1 has never exhibited these behaviors in the past and the outcome was R1's behavior may be related to recent change in medication. During the visit, LPA observed that there were three caregivers providing service and supervision during meal service in the dining room. R1 was assisted with feeding by one of the Medication Technicians and R1 observed to be restless and walked away from the sitting area several times while being assisted with feeding. 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 LPA interviewed three caregivers regarding to supervision in the dining room during meal services and they reported that there are three caregivers assigned in the dining room during meal service. One of them would go back and forth to escort residents from their rooms to the dining room for their meals while the other two stay in the dining room providing supervision for the residents who are in the dining room. In addition, they stated that they have increased supervision and they are providing one to one meal service for R1 since the incident and there are no further incidents. No deficiency is cited today. This report is reviewed, discussed with the Executive Director, a copy is provided.