Brookdale Brookhurst.

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today's visit was to conduct a case management. LPA Tea was greeted and granted entry into the facility by Executive Director (ED) John Goodwin. On this day LPA Tea amended LIC809 and LIC809D dated 10/28/2025. LPA reviewed amended report with ED Goodwin. An exit interview was conducted with Executive Director John Goodwin. A copy of this report and amended LIC809 and LIC809D along with LIC9102TV were provided to the facility.

medication. Although R1 had complex medical conditions, including liver cirrhosis, anemia, interstitial lung disease, and later hepatic encephalopathy, there was no physician designation indicating R1 was a fall risk. Facility records such as staff progress notes show that R1 experienced a significant and progressive decline in medical condition, including confusion, disorientation, weakness, and repeated hospitalizations. Documentation reflects that R1’s condition worsened following hospital discharges, particularly after episodes related to elevated ammonia levels and liver disease complications. The facility appropriately updated R1’s Personal Service Plan (PSP) multiple times (05/13/22, 05/18/22, and 05/23/22) in response to their changing condition. These updates included added assistance with medication management, dressing, grooming, and toileting. Although escort mobility assistance was briefly implemented and later removed, documentation supports that services were adjusted based on observed needs and condition changes. Incident reports indicate that R1 experienced multiple falls, many of which were unwitnessed or occurred while attempting to act independently, such as trying to get into bed or ambulate without assistance. Injuries documented were generally minor with skin tears and bruising, and staff responded appropriately by providing first aid and seeking medical evaluation when necessary. Medical records from Orange Coast Memorial indicate that at the time of hospitalization, R1 was alert, oriented, well-developed, and non-toxic appearing, with no signs of neglect. After the fall, a brain bleed was suspected, but R1’s decline was mainly caused by pneumonia, respiratory failure, and septic shock, which led to their death. The medical records review does not indicate or specify correlation between R1’s falls and her overall medical deterioration or death. Instead, documentation supports that their decline was primarily due to underlying chronic and acute medical conditions. In the medical records, it was also notated that R1’s family expressed satisfaction with the facility’s care and denied any concerns regarding staff. LPA conducted interviews with current facility staff who worked when R1 was present at the facility. All staff interviewed consistently reported that R1 experienced a noticeable decline in condition, including increased confusion, weakness, and frequent hospitalizations. Staff indicated that R1 preferred to maintain independence and often attempted tasks without assistance, which contributed to their falls. Staff also stated that R1 did not like to ask for help. All interviewed staff reported that they provided appropriate care and (Complaint investigation continued on LIC9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 supervision, monitored R1’s condition, and responded to incidents as they occurred. Staff further indicated that R1’s sister expressed appreciation for the care provided and felt reassured by staff support. Although R1 experienced multiple falls while residing at the facility, the evidence supports that these incidents were largely associated with R1’s declining medical condition and attempts to remain independent, rather than neglect or lack of care by facility staff. The facility responded appropriately by updating care plans, monitoring R1’s condition, and ensuring medical attention when needed. Therefore, based on the records reviewed and interviews conducted, there is insufficient evidence to conclude that the facility’s actions directly caused or contributed to serious injuries resulting from the falls. The allegation mentioned above has been determined to be UNSUBSTANTIATED, meaning 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. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report and confidential names list were provided to the facility.

The Physician’s Report dated June 15, 2023, states R1 was unable to administer own prescription medications but was able to self-administer PRN medications and safely store medications. The “Medication Release When Resident is Absent from the Residence” form indicates R1 and the daughter handled medications independently. The Personal Service Plan dated July 21, 2023, states R1 self-manages medications, including administering, ordering, coordinating, and storing medications safely. A witness reported concerns that the facility charged for medication management services while allegedly not providing adequate assistance and believed R1’s health decline was related to poor medication management. The witness also expressed concern that the facility delayed reassessing R1’s medication needs. However, the witness’s statements were not supported by facility records or corroborated by other interviews. LPA interviewed the facility’s Long-Term Care Ombudsman, who stated she regularly attends resident council meetings and has not received complaints or concerns regarding medication mismanagement. She indicated the most common concern is residents wanting medications administered exactly on time, noting the one-hour allowable window for medication administration. LPA interviewed eight residents. Most residents reported they manage their own medications. One resident reported medication management services were satisfactory initially but later experienced delays and forgetfulness. Two residents reported receiving medication management services and stated they had no issues. One resident receiving medication management services expressed a preference to self-manage medications due to cost; however, facility staff were following a nurse practitioner’s order requiring facility-managed medications. It was alleged that facility has not eradicated the cockroach problem. Upon investigation staff consistently reported the presence of cockroaches, sometimes referred to as water bugs, as a seasonal issue rather than an infestation. Staff stated the facility is located near a canal and that pests may enter through drainage systems. Staff reported the facility has taken proactive measures, including installing additional mesh barriers on drains to prevent pests from entering. Pest control records from Ecolab document monthly pest maintenance services, bait trap monitoring, and on-call services as needed. The Maintenance Director, Cristian Hernandez confirmed Ecolab services the (Complaint investigation continued on LIC9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 facility monthly and that the facility maintains in-house pest control products for immediate response. He stated the facility avoids toxic chemicals due to concerns about water supply safety and emphasized ongoing pest management rather than complete eradication. LPA also spoke to the facility ombudsman stating there were no complaints or concerns related to cockroaches or pest infestations during resident council meetings. LPA interviewed eight residents, all of whom denied experiencing cockroach or pest issues and stated the facility responds appropriately to pest concerns. Therefore, based on record review and interviews, there is insufficient evidence to substantiate that R1 was not receiving medications in a timely manner due to facility noncompliance. Records consistently indicate R1 self-managed medications or shared responsibility with the daughter, and there is no documentation showing a failure by the facility to administer medications when responsible. Based on interviews and documentation reviewed, the facility has implemented ongoing and reasonable pest control measures and there is no evidence of an unresolved cockroach infestation. The facility demonstrated consistent pest management efforts and resident reports did not corroborate the allegation. The allegations mentioned above has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director John Goodwin. A copy of the report and confidential names list were provided to the facility.

completed prior to move-in indicate that R1 bruises easily and required a high level of assistance. Four out of four facility staff interviewed stated that R1 had visible bruising prior to admission. Three staff reported observing R1’s private caregiver handling R1 roughly during transfers. Staff also reported observing the same private caregiver handle R1’s great-grandson, who has special needs, in a rough manner during visits to the facility. All staff interviewed stated they handled R1 with care, particularly due to frequent family monitoring. Two witnesses expressed concerns regarding R1’s care and believed R1 did not require a two-person assist; however, facility records and assessments completed prior to admission indicate R1 required extensive assistance. Witnesses interviewed corroborated that one staff member initially expressed discomfort assisting R1 alone and requested additional assistance, consistent with the documented care plan. Emergency department discharge paperwork from Kaiser indicates the treating physician believed R1’s elbow bruising and swelling were not related to infection or other emergent conditions and were most consistent with a minor injury expected to improve within two weeks. It was alleged that staff did not administer resident’s medication . Four out of four staff interviewed stated that R1 did not have complete or valid physician orders for several medications during their stay. Facility Progress Notes document multiple instances where medications brought in by the family or private caregiver did not match physician orders, including incorrect medication strength and missing orders. On January 22, 2025, records indicate that medication was delivered by the family without a corresponding physician order for essential medication, including Carbidopa/Levodopa for Parkinson’s disease. Progress notes reflect the facility made ongoing efforts to obtain appropriate physician orders, including attempts made up to R1’s move-out date of February 22, 2025. Documentation indicates the family was aware that physician orders were required for medication administration. Staff consistently stated they could not legally administer medication without a valid physician order and were required to follow Title 22 requirements. The Physician’s Report dated December 30, 2024, completed by a Physician Assistant, indicates medication (Complaint investigation continued on LIC9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 management responsibilities were handled by R1’s private caregiver. The LPA also interviewed the Ombudsman, who attends resident council meetings and reported no known complaints regarding medication mismanagement at the facility. Resident interviews revealed varied experiences with medication management; however, these statements were general in nature and not specific to R1. Two residents reported satisfaction with medication services, and no residents provided information corroborating medication mismanagement related to R1. Therefore, based on documentation, medical evaluation, and consistent staff statements, there is insufficient evidence to conclude the bruising occurred as a result of facility staff actions or neglect. Based on documentation showing the absence of required physician orders, the facility’s documented efforts to obtain orders, and staff adherence to regulatory requirements, there is insufficient evidence to conclude the facility failed to administer medication improperly. The allegations mention above has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director John Goodwin. A copy of the report and confidential names list were provided to the facility.

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing Division (CCLD) on Oct 8, 2025, submitted by Health and Wellness Director (HWD) Suzette Paige. LPA was greeted and allowed entrance into the facility by Executive Director (ED) John Goodwin. LPA explained the reason for the visit. The department received an incident report regarding elopements of a memory care resident, Resident 1 (R1) that happened on October 1, 2025 and October 7, 2025. During the visit, LPA and ED Goodwin toured the facility and inspected Clare Bridge Memory Care unit and R1's room. LPA conducted a health and safety check on R1 and observed no health and safety issues. Based on LPA's observation and review of records, despite R1 having a diagnosis of Alzheimer's, R1 is very cognitive, high functioning and very alert. LPA toured and observed the rest of the facility and found no health and safety issues. LPA requested and reviewed copies of R1’s resident file. LPA Tea spoke to staff and management regarding R1's care and the elopements. One of the delayed egress on the doors in the memory care unit in which R1 has exited out of, has an alert that is not loud enough for staff to hear. The alert does go to the front desk and 2nd floor of the facility, and staff has caught the alerts in time during each elopement. Currently the facility has fixed the annunciator alert for the delayed egress in the memory care unit to be more audible and louder and added additional siren alert as of yesterday, Oct 8, 2025. R1 is very quick and can run fast but each elopement they were able to bring him back to the facility within in a short matter of time, no more than 20 mins and less than a mile away from the facility. The facility did follow elopement protocols and contacted local law enforcement. They contacted the family and R1's primary care physician. Facility was was able to redirect him to the facility and ensure that he (Report continued on LIC809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 was safe. Facility management believes R1 needs a higher level of care. With proper mitigation, the facility has been keeping a close observation on R1 and since the last elopement the facility has had the family hire a one to one personal caregiver from 7:00 AM to 7:00 PM for R1. After the hours of the personal caregiver, the facility has assigned a facility caregiver staff to be with R1 till bedtime and monitoring throughout the night. Based on the observations made during today’s inspection, no deficiencies are being cited at this time. An exit interview was conducted with Executive Director John Goodwin and Health and Wellness Director Suzette Paige and a copy of this report was provided at exit.

among the seven residents interviewed. LPA spoke to two residents who shared a room together. One resident, Resident 1 (R1) interviewed, felt the facility did not do anything enough and felt their privacy was violated. The resident complained that their roommate played the television 24 hours non-stop. The facility had made both residents come to an agreement but R1 did not feel the roommate did not follow the agreement and remained unresolved. Two staff interviewed felt the facility did their best to accommodate their privacy with residents who shared an apartment together. They offered solutions with residents but with R1, they did not like the options and had made up their mind of leaving the facility. It was alleged that staff inappropriately removed resident’s door. Staff explained to LPA that residents who share an apartment together share the entire space together. There are no designated spaces for any of the residents in the shared apartment. Residents are fully aware when they move in that the entire space of the room is shared. Some shared resident rooms have a door because if not shared, the apartment is a one-bedroom apartment. When it is shared the apartment is called a semi-private or companion suite and residents can decide if they want to keep the door or remove it. If the door remains in the shared apartment, the staff remind the residents to be mindful of sharing the entire space together and that the facility can remove the door if needed when issues occur between residents. With two of the nine residents interviewed, residents had an issue with each other where one resident closed the door not allowing the air conditioning to come through the entire apartment. The other resident had problems with the television noise. As a result of them having issues, the staff removed the door. Two of the staff interviewed did say that both residents agreed to have the door being removed. R1 said they did not agree to it. One staff member said after the agreement was made between R1 and their roommate, R1 said the noise was better and gave permission to remove the door. Since the entire space of the apartment is shared all residents have access to any part. Residents signed the admission agreement in where the section, “Alterations” acknowledges that the facility may make alterations to meet the requirements of any applicable law or regulation. In this case both residents are not afforded equal access to the shared space, so the facility made the decision to take the door down. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations staff are not ensuring resident is accorded privacy and staff inappropriately removed resident’s door has been determined to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Complaint Report continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 No deficiencies cited at this time and an exit interview was conducted with Executive Director John Goodwin. A copy of the report and confidential names list were 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 The residents share the bathroom, closet, kitchenette and the rest of the suite, it is accounted for as one shared space. Two facility staff interviewed said residents who sign up for these rooms are aware before moving into these shared suites that everything is shared and there is no room or part of the room given to a resident. One staff member explained that residents were explained and shown the configurations of the suites prior to moving in during a room tour. The residents accepted and were aware that everything in the suite space must be shared and all residents have equal access to the space. 8 out 9 residents confirmed they were aware about moving into a shared space and the nature of the space prior to moving in. Therefore, based on LPA Tea's observations, interviews conducted, and records reviewed the allegation that staff did not ensure resident’s room was not used as a passageway to the bathroom has been determined as UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies cited at this time and an exit interview was conducted with Executive Director (ED) John Goodwin. A copy of the report was provided to the facility.

Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to the facility today to conduct a continuation of the annual required inspection. LPA was greeted and granted entry by the facility staff and explained the reason for the visit. Executive Director (ED) John Goodwin arrived shortly after to assist with the continued annual inspection. During today’s visit, LPA Tea reviewed medication storage and administration. Medications are stored in locked carts on different floors of the facility. Medications are being administered per physician’s order. LPA spoke to staff that were present regarding care provided. During the visit LPA Tea observed residents having breakfast and lunch in the dining area. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED John Goodwin and a copy of this report was given to the facility.

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by front desk staff and explained the reason for the visit. Executive Director (ED) John Goodwin and Business Operations Manager (BOM) Danielle Chairez arrived shortly to assist with the visit. Facility is licensed for 148 non-ambulatory residents, of which 22 may be bed-ridden, but limited to the first and second floor, and a hospice waiver for 22 residents. Currently there are 113 residents and 7 are on hospice during today's visit. LPA Tea reviewed twelve resident files and six staff files. Resident files and staff files contained all the required documentation. ED Goodwin’s administrator certificate expires on July 24, 2025. ED Goodwin completed and submitted all course work to renew his certificate and is pending approval. The last disaster drill was conducted on June 6, 2025. LPA Tea along with ED Goodwin toured the facility at 2:10 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a three-story building, with a memory care wing, called “Clare Bridge” on the first floor. In the middle of the building is a courtyard with shaded patio seating and a fenced in water fountain with koi fishes swimming. Memory Care unit has a garden sitting area of its own in the back that is secured. LPA tested delayed egress around the memory care garden to be operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. LPA observed evac chairs in every stairwell in the facility for emergencies. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 118.4 to 110.6 Fahrenheit degrees. LPA pulled emergency pendants in resident’s bathrooms. The first test, the Annual inspection report continued on LIC809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 emergency pendent was not working properly. The facility did not receive a signal or notification. ED Goodwin will check to make sure all emergency bathroom pendants are operating. The second time it was tested, staff came within in 15 minutes. LPA tested the resident push pendant and staff came within in less than 10 minutes to respond to the call. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen and dining room were inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed emergency food and water supplies stored in storage areas in the facilities. During the visit, LPA observed residents having lunch and early dinner. LPA also observed residents playing card games and partaking in activities in the activity room. LPA interviewed clients regarding their quality of care. Due to time constraints, LPA will return to the facility at a later time this month to finish the annual inspection. At this time, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations An exit interview was conducted with ED John Goodwin and a copy of this report was given to the facility along with a copy of the LIC 858, 858C; and 859.

living with other residents and how the resident does not get along with their paired roommates. He gave the resident notice that the options are starting to be limited, either they must get along or they will have to pay the price for a private room which the resident can not afford. Another staff interviewed said there has never been any staff or management to their knowledge giving verbal threats of eviction to residents. Also, the staff said it could be a miscommunication about staff addressing concerns to a resident about their living situations or issues. Per interviews with residents, two out of three residents interviewed have address that they never heard the facility verbally threatened residents with an eviction. One resident has heard rumors or hearsay about some residents that will be evicted from residents in the community. One witness said that a resident feels that they are going to be evicted. It was alleged that facility staff is spreading lies about resident. The investigation determined the following: ED Goodwin stated the facility staff does not talk about resident evictions or any issues with residents. If it pertains to a resident who is being evicted, it would be addressed directly to the resident who is being evicted in a formal professional manner. Another staff has stated that there would be no facility staff spreading lies about resident, it is very unprofessional. The staff believe that residents would be spreading lies in the community, some would lie and make up stories. Per interviews with residents two out three have agreed that they never heard the facility staff spread lies about resident. A witness addressed that a resident likes all the staff here and that they do not spread lies but is disappointed in one staff who feels they are making up a story about them. The witness explained that resident likes living here and gets along with everyone and is well liked. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations that facility staff is verbally threatening resident with eviction and facility staff is spreading lies about resident has been determined to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director John Goodwin. A copy of the report was provided to the facility.

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today's visit was to conduct a case management. LPA Tea was greeted and granted entry into the facility by Executive Director John Goodwin. On this day LPA Tea amended LIC809, LIC809C dated 08/12/2024. LPA reviewed amended report with Executive Director. An exit interview was conducted with the executive director . A copy of this report and amended LIC809, LIC809C was provided to the facility.

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing (CCL) on August 9, 2024, submitted by Health and Wellness Director (HWD) Suzette Paige, LVN. LPA was greeted and allowed entrance into the facility by Executive Director (ED) John Goodwin. LPA explained the reason for the visit. During the inspection, LPA and ED toured the facility and inspected R1’s room. LPA conducted health and safety checks on residents present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA checked perishable and non-perishable food supply and it was adequately stocked at time of visit. The electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA interviewed ED Goodwin and requested and reviewed copies of R1’s resident file and S1’s staff file. On August 7, 2024, facility management concluded their investigation, S1 emailed their resignation before receiving investigation results. Facility management concluded they were going to terminate S1 employment. In Guardian, S1 has been shown to be separated on August 7, 2024. There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited at this time. An exit interview was conducted with Executive Director, John Goodwin and a copy of this report was provided at exit. **THIS IS AN AMENDED REPORT** 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 This page was created in error. **THIS IS AN AMENDED REPORT**

(R1) was newly diagnosed with Parkinson disease on March 20, 2024. Personal service plan dated October 05, 2023, page 4 indicates R1 ambulates with a rolling walker independently throughout the community, although R1 prefers to stay in their room or in bed most of the time. R1 has episodes of dizziness and anxiety that causes R1 to have tremors and is prone to bedsides and bathroom falls. Staff to remind R1 to use call light pendent, request and wait for staff assistance when feeling anxious or dizzy. Staff to observe environment when assisting with meds, care and remove hazards. Remind R1 to wear non-skid sole slippers/shoes while ambulating. Communicate with primary care physician regarding falls and residents’ safety. Unusual incident/injury reports submitted to the Department reflect that facility has called 911 immediately upon R1 having falls. Report also indicate that R1 has had subsequent non-injury falls due to non-compliance with use of assistive device despite staff re-orientation and reminder to use walker. Reports indicate that on March 20, 2024 R1 was admitted to hospice care and service plan to be updated and reflect current needs. Tour of R1’s bedroom LPA observed a rollator walker with seat in the bathroom. Interviews with 4 of 4 staff indicate that the facility since resident had more fall implemented safety checks about two times every hour. Staff indicated that R1 does not like carrying pendent, forgets it or simply refuses to use it. Staff indicated that R1 must be reminded to use the walker even on short distance walks. Staff constantly remind R1 the importance of the pendent and to wear it as well as the importance of using the walker for ambulation assistance. R1 has always been very independent but facility has been proactive on implanting stand assist for R1 as needed and when requested. Staff indicated that they encourage proper use of assistive devices and additional personalization for falls management based on R1’s history and diagnosis while balancing independence, dignity, and choice. Based on the information gathered during the investigation, the Department is unable to ascertain if the allegation 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. This report was reviewed with Executive Director and a copy was furnished to the facility.

R1 was discharged from the hospital and returned to the facility on January 6, 2024 by R1’s family. Per R1’s discharge paperwork, R1 showed signs of delirium, but no hospital documentation indicated that R1 had skin breakdown. On January 7, 2024, R1 began home health services with Excell Home Health, and R1 was assessed by the nurse, who also did not report or observe any skin issues. On January 14, 2024, facility staff observed wounds on R1’s sacrum and buttocks while changing R1, and staff notified the home health nurse who cleaned and dressed R1’s wound the same day. On January 15, 2024, when R1 was being changed, staff observed that R1’s wounds had worsened, therefore, sent R1 out to the hospital to obtain further medical evaluation. An interview was conducted with R1’s family who stated that the facility is not to blame regarding R1’s condition and expressed satisfaction regarding the facility care given to R1. Based on interviews which were conducted, review of documents obtained, and observations, there is insufficient evidence to ascertain if the allegation occurred as reported, therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with BOM Chairez. A copy of this report was provided and explained.

Per documentation review, R1 is able to bathe, and dress self, is not diagnosed with mild cognitive impairment or dementia, is ambulatory, has a history of falls, and when R1 is anxious, R1 will engage in behavior such as placing self on the floor. Documentation revealed that R1 had one fall on January 30, 2024, and sustained no other falls the month prior and after. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation 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 HWD Paige. A copy of this report was provided and explained

During the course of the investigation LPA reviewed documents including the Smartcare pendant call log dated 09/25/23 and 09/26/23. Per Smartcare pendant call log the average staff respond time ranges from one minute to 59 minutes. Regarding the allegation that facility’s signal system is not functioning properly, the investigation revealed the following: Three of four residents interviewed denied the allegation. Per interviews conducted with residents it was reported that the signal system does not always work but that if the pendant is not working properly that staff will replace it within 15 minutes. It was reported via interviews by Staff 1 (S1) that sometimes the pendants do not work properly but that it will get replaced right away. Per S1 the signal system has been working properly. Based on LPA's observation and information gathered during the investigation, 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, the allegations are deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with ED Goodwin, and a copy of this report was provided to the facility.