Staff stated that they began actively looking for R1 when R1 could not be located for their evening medication pass. Staff elevated R1’s absence per protocol through their chain of command, and R1 was located on the ground within the enclosed gated yard where residents were allowed to freely roam. Staff assessed R1 for injuries and notified R1’s Hospice agency as well as their Responsible Party. Staff additionally informed that the outside doors to the enclosed yard areas remained unlocked and open often throughout the day, per the facility’s “51 Standards” model for memory care residents. Staff stated unanimously that R1 did not have any physical injuries after the incident, with the exception of a possible minor cheek abrasion/redness. Staff stated they were unsure if the cheek abrasion was from the incident on 08/02/2025, or from a different injury due to R1’s pattern of frequent falls.

Review of facility records corroborated staff statements regarding the timeline of events. The facility’s internal incident report and written statements from staff were consistent with staff statements made during interviews. Progress notes for R1 showed that R1 was placed on alert charting during the timeframe of concern and showed no signs of discomfort or pain after the incident occurred, vitals in normal range, and R1 presented at baseline. The facility’s “51 Standards” document stated that “Outside doors to enclosed yard areas are open every day and must remain open from 7:00am to 9:00pm”, corroborating staff statements that R1 was allowed to freely walk around the gated yard where they were found. Records did not give evidence that R1 was not being supervised according to their care plan during the time of incident.

An outside medical professional familiar with R1 (OS1) was interviewed; OS1 informed that R1’s baseline was to walk around the facility for long periods during the day. OS1 additionally informed that due to cognition, R1’s walking pattern was absent of R1 looking down to see where they stepped, resulting in frequent falls. OS1 informed that a fall mitigation plan was in place with ongoing care plan updates between the facility, R1’s Responsible Person, and R1’s Hospice agency. OS1 informed that they frequented the facility due to being involved with multiple residents and did not have concerns regarding the facility’s supervision of R1 or other residents. A second outside source (OS2) from an advocacy agency was interviewed; OS2 informed that they had not conducted an investigation regarding the incident at the time of the call, however based on prior visits they had no concerns about supervision at the facility.

(Continued on LIC9099 p.3)

During an unannounced facility visit LPAs Patterson and Ngallo walked the perimeter of the property; LPAs observed all gated yard areas to be enclosed and locked. LPAs additionally observed resident care in each neighborhood; LPAs observed residents being assisted by staff with activities of daily living (ADLS). No residents were observed to be waiting for care or in an unsafe or unsupervised location.

LPAs attempted to interview R1, however due to R1’s major neurocognitive disorder they were not able to be qualified for interview. LPAs found observations of R1's gait and walking pattern to be consistent with staff and outside source statements.

Regarding the allegations “Staff made false statements regarding resident incident”, and “Staff falsified records”, eight (8) of eight (8) staff members involved in the incident denied that they were instructed by management or another staff member to make false statements or omit information regarding R1’s incident, including written documentation of the incident. Staff informed that the interview statements and written statements were true and accurate to the incident. Each staff member was interviewed privately, and their statements/recollection of events were consistent with other staff statements and records.

Two outside sources were interviewed regarding the allegations. The information provided by R1’s Hospice agency was consistent with the information provided by the facility. While OS2 had not yet conducted an investigation regarding the incident, they did not express concerns of the facility’s truthfulness regarding resident incidents.

Review of facility records did not corroborate the allegations. Staff written statements and incident reports of the event corroborated verbal statements during interviews. Additional records revealed that an internal investigation was conducted by the facility’s Human Resources department, and no evidence was found that staff falsified details of R1’s incident or were instructed to do so. No records were found to give evidence to falsified statements or falsified records.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Calais Anguiano, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.