Lo-har Senior Living

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings for the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Wellness Director Jenna Purnell. On November 14, 2023, Community Care Licensing (CCL) received a complaint alleging neglect to Resident 1 (R1) resulted in R1 sustaining a bedsore, staff did not provide Resident 2 (R2) with an appropriate living arrangement, staff did not prevent Resident 3 (R3) from causing harm to Resident 4 (R4) and Staff did not properly report an incident to R4’s responsible party. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated October 27, 2022, R1 is confused/disoriented and is non-ambulatory. According to interviews with staff, R1 is actively receiving Home Health visits for Stage II pressure ulcer. UnsubstantiatedRead the full finding— CDSS inspection report, December 12, 2023 · control 08-AS-20231114135318

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Executive Director Jared Green and discussed the purpose of the visit. On February 6, 2023, Community Care Licensing (CCL) received a complaint alleging licensee was not issuing medication as prescribed. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, licensee did not order medication timely and medication was not distributed according to prescription. Additionally, on November 14, 2023, CCL received additional information alleging that medication is not being issued as prescribed as medication has been found on the floor of residents rooms. SubstantiatedRead the full finding— CDSS inspection report, November 20, 2023 · control 08-AS-20230206145343

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Wellness Director Jenna Purnell. On October 26, 2023, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) is not allowed to use the facility telephone to contact outside sources. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated September 27, 2023, R1 can communicate need and is blind. According to interview with R1, R1 has access to a telephone in their cottage and states they can request assistance from staff to make telephone calls. Interview with staff revealed that R1 often asks for assistance with telephone use and staff regularly assist. UnsubstantiatedRead the full finding— CDSS inspection report, November 2, 2023 · control 08-AS-20231026140006

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Executive Director Jared Green and discussed the purpose of the visit. On September 14, 2023, Community Care Licensing (CCL) received a complaint alleging staff failed to provide activities for residents. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation, conducted interviews and made observations. According to allegation there have been no continuous activities available to residents for the month of September 2023. Interviews with multiple residents revealed that there are no consistent activities available to them. Interview with staff revealed some activities are available but there are times when there is no available staff to complete activities with residents. During multiple visits, LPA Strong did not observe any active resident activities. Continue on LIC 9099-C SubstantRead the full finding— CDSS inspection report, October 25, 2023 · control 08-AS-20230914202256

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Jared Green. On October 5, 2023, Community Care Licensing (CCL) received a complaint alleging facility staff financially abused Resident 1 (R1). During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to R1’s Physician Report signed July 13, 2023, R1 can leave facility unassisted and can communicate needs. Additionally, R1 records collected revealed that R1 has had recent increases of agitation towards staff and roommates. According to allegations, there have been multiple undescribed incidents of suspicious activity to R1’s bank account. Facility financial records reviewed did not reveal any unauthorized withdrawals from R1’s bank account. UnsubstantiatedRead the full finding— CDSS inspection report, October 25, 2023 · control 08-AS-20231005140109

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to continue an investigation on the above mentioned complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Jared Green and Wellness Director Jenna Purnell. On September 12, 2023, Community Care Licensing (CCL) received a complaint alleging neglect resulted in Resident 1 (R1) suffering a medical emergency, Resident 2 (R2) records were not maintained and staff did not provide R2 with a bed. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated August 11, 2023, R1 is diagnosed with a major neurocognitive disorder, is confused and disoriented but is able to follow instructions and communicate needs. UnsubstantiatedRead the full finding— CDSS inspection report, September 27, 2023 · control 08-AS-20230912164202

Licensing Program Analyst (LPA) Amy Domingo conducted a complaint investigation visit to deliver findings for the above allegation. LPA Domingo met with Wellness Coordinator Jenna Purnell. The Department’s investigation consisted of record reviews, interviews with staff, and outside sources. It was alleged that Resident 1 (R1) (See LIC811 list of confidential list of identification) was hit by staff. An outside source 1 (OS1) was interviewed and there has not been any reports by residents of staff hitting the residents. Outside Source 2 (OS2) was interviewed and there has been no observations of staff mistreating residents. [Continued on LIC9099C] UnsubstantiatedRead the full finding— CDSS inspection report, September 25, 2023 · control 08-AS-20230614154953

Licensing Program Analyst (LPA), Natasha Persaud concluded the complaint investigation regarding the above mentioned allegation. LPA met with Wellness Director, Jenna Purnell. During the investigation, records were reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that staff were physically rough when assisting Resident #1 (R1). It was reported, a staff grabbed R1 harshly on 08/09/23 causing left side hip pain. R1’s Physician's Report dated 12/27/19 indicated R1 has paralysis on the left side of their body. R1’s Primary Care Nurse Physician reported R1 was a paraplegic that can feel from their left hip down but not from the left hip up. R1’s Primary Care Nurse’s Physician assessed R1 on 08/02/23 and 08/09/23 for hip pain and did not observe any injuries or trauma. Evidence obtained revealed R1 was wheelchair bound and leans to the left side of their wheelchair, which could cause friction or pain. Outside source interviews stated R1 has a histRead the full finding— CDSS inspection report, September 20, 2023 · control 08-AS-20230811100404

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Jared Green. Wellness Director Jenna Purnell arrived shortly after. On September 1, 2023, Community Care Licensing (CCL) received a complaint alleging facility is in disrepair. During investigation, LPA Strong collected pertinent facility records, conducted a facility inspection, and conducted interviews. According to the allegation, the facility’s main building has a water leak in the ceiling that is affecting the residents and the building. During the investigation LPA Strong conducted a facility inspection and observed an active ceiling leak. Interview with Executive Director revealed that the leak is being caused by an old heating, ventilation, and air conditioning system (HVAC). UnsubstantiatedRead the full finding— CDSS inspection report, September 8, 2023 · control 08-AS-20230901114200

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Wellness Director Jenna Purnell, and Executive Director Jared Green and discussed the purpose of the visit. On July 25, 2023, Community Care Licensing (CCL) received a complaint alleging staff handled resident in a rough manner and staff spoke inappropriately to resident. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, on July 11, 2023, Resident 1 (R1) had an outburst that resulted in Staff 1 (S1) grabbing R1 by the wrists in a rough manner. Records collected revealed R1 is diagnosed with a major neurocognitive disorder and has a history of aggressive behavior. Interviews revealed that on the date of the incident, R1 had an emotional outburst and began yelling at staff and residents. Interviews also revealed that a witness presentRead the full finding— CDSS inspection report, August 30, 2023 · control 08-AS-20230725121931

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to open a complaint investigation on the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Wellness Director Jenna Purnell. On August 28, 2023, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) was physically abused by an unknown source. During today’s visit, LPA Strong conducted interviews, and reviewed facility records. According to allegations, on August 11, 2023, R1 was sleeping in the living room of their cottage when an unknown person hit R1. UnsubstantiatedRead the full finding— CDSS inspection report, August 30, 2023 · control 08-AS-20230828141929

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to open a complaint investigation on the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Wellness Director Jenna Purnell. On August 23, 2023, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) was not afforded privacy during phone calls. During today’s visit, LPA Strong conducted interviews, a facility inspection and reviewed facility records. According to R1’s Physician Report signed July 13, 2023, R1 can leave facility unassisted and can communicate needs. Additionally, R1 records collected revealed that R1 has had recent increases of agitation towards staff and roommates. UnsubstantiatedRead the full finding— CDSS inspection report, August 30, 2023 · control 08-AS-20230823100915

Licensing Program Analyst (LPA) Tiffany Holmes conducted a complaint visit to close out the investigation. LPA was greeted at the front by Jenna Purnell, Wellness Coordinator and granted entry after identifying herself and disclosing the reason for her visit. It was alleged that staff gave an illegal eviction to a resident. Interviews revealed there was no notice to the resident to move. At the time of the visit the resident in question was in their room and has not been given an eviction notice. Interviews revealed there was talks of evicitng the resident but no action was behind it. Interviews did not reveal that staff gave an illegal eviction to the resident. UnsubstantiatedRead the full finding— CDSS inspection report, August 29, 2023 · control 08-AS-20230711171149

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Wellness Coordinator Jenna Purnell and discussed the purpose of the visit. On May 11, 2023, Community Care Licensing (CCL) received a complaint alleging licensee did not report change in medical condition to Resident 1 (R1) and Resident 2 (R2). During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegations, on May 10, 2023, R1 arrived at their medical appointment with a change in medical condition that was not previously reported to medical provider. Medical records collected for R1 revealed that medical provider was not previously notified of R1’s change in mental and physical functions as such that R1 was unable to maintain upright posture which was different than their baseline. Interview with outside source revealed that there was no communicRead the full finding— CDSS inspection report, July 26, 2023 · control 08-AS-20230511103922

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Wellness Coordinator Jenna Purnell. On May 22, 2023, Community Care Licensing (CCL) received a complaint alleging facility staff took Resident 1’s (R1) personal items without permission, staff verbally threatened R1 and staff did not treat R1 with dignity and respect. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated August 2, 2022, R1 is diagnosed with a major neurocognitive disorder, is disoriented, and can communicate needs. UnsubstantiatedRead the full finding— CDSS inspection report, July 26, 2023 · control 08-AS-20230522090909

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Administrator Rhon Hipolito. On May 12, 2023, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) sustained an injury due to neglect. During the investigation, LPA Strong conducted interviews, and reviewed facility records. According to allegations, on May 11, 2023, R1 was observed to have a large new bruise to the left eye. According to R1’s Physician Report signed August 4, 2022, R1 is diagnosed with a major neurocognitive disorder, does not require continuous bed care and is able to communicate needs. Additionally, R1 Service Plan signed March 15, 2023, R1 requires assistance with transfers and is non-ambulatory. Interview with outside source revealed that a large healing bruise was seen on R1’s left eye on May 8, 2023. UnsubstantiatedRead the full finding— CDSS inspection report, June 26, 2023 · control 08-AS-20230512154008

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Administrator Rhon Hipolito. On June 12, 2023, Community Care Licensing (CCL) received a complaint alleging facility is functioning without an administrator and facility has untreated pests. During the investigation, LPA Strong conducted a facility inspection, conducted interviews, and reviewed facility records. According to allegations, the facility has been conducting regular business without a facility administrator. Records revealed that LPA Strong was informed of new administrator as of May 31, 2023, via in-person conversation with Operations Resource Specialist. Records also revealed new administrator has an active certification verified on the Community Care Licensing website. UnsubstantiatedRead the full finding— CDSS inspection report, June 26, 2023 · control 08-AS-20230612113701

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Administrator Rhon Hipolito. On June 14, 2023, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) eloped from the facility due to neglect. During the investigation, LPA Strong conducted interviews, and reviewed facility records. According to allegations, R1 has continuously eloped from the facility within the last six months. According to R1’s Physician Report, R1 is diagnosed with a major neurocognitive disorder, is not allowed to leave facility unassisted and has wandering behavior. Additionally, R1 Service Plan, R1 does not require incontinence care but does require safety checks. According to staff interviews, R1 has not left facility five times within the last six months. UnsubstantiatedRead the full finding— CDSS inspection report, June 26, 2023 · control 08-AS-20230614101535

Licensing Program Analyst (LPA) Marisela Garcia-Centeno made an unannounced visit to open an investigation and deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit. LPA met with Wellness Director, Amy Castillo and Administrator, Ducharme-Franklin, Kandy and discussed the basic elements of the complaint. The Department investigated the above listed complaint allegation. The investigation consisted of a tour of the facility and multiple interviews with residents and staff. On April 26, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not provide residents clean linens on a weekly basis. During a visit conducted on April 28, 2023, the linens for five (5) residents were observed with stains and were heavily soiled with what appeared to be bodily fluids. The mattress pads and sheets were observed to be wet and had urine smell. During interviews with residents, it was indicated that their linens hadRead the full finding— CDSS inspection report, April 28, 2023 · control 08-AS-20230426115034

Licensing Program Analyst (LPA), Natasha Persaud concluded the complaint investigation regarding the above mentioned allegations. LPA met with Wellness Coordinator, Jenna Purnell During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged, staff did not ensure residents received their meals. The allegation is involving Resident #1 (R1) sleeping in a chair and not being woken up by staff to eat meals. Outside source interviews revealed R1 was not provided a meal on two separate occasions in February 2023, date unknown, due to staff not waking R1 up to eat. R1’s Physician Report dated 11/15/22 indicated R1 has a Major Neurocognitive Disorder and is able to feed themselves. R1’s responsible party’s interview disclosed they visit R1 daily and assists with feeding R1 their dinner. R1’s responsible party stated R1 doesn't eat much, even with them feeding R1. R1’s responsible party confirmed iRead the full finding— CDSS inspection report, April 13, 2023 · control 08-AS-20230221102652

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Administrator Kandy Franklin. On December 19, 2022, Community Care Licensing (CCL) received a complaint alleging neglect/lack of supervision resulted in injury to Resident 1 (R1). During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated July 7, 2022, R1 is diagnosed with mild cognitive impairment, is confused and disoriented, does not require continuous care, can leave facility unassisted, and has a wandering behavior. R1’s Individual Care Plan signed March 28, 2022, revealed R1 is independent with toileting and eating, and is forgetful. UnsubstantiatedRead the full finding— CDSS inspection report, April 7, 2023 · control 08-AS-20221219104810

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Wellness Coordinator Jenna Purnell. On June 13, 2022, Community Care Licensing (CCL) received a complaint alleging staff did not prevent a resident from wandering away from facility, and staff did not address a resident's change in medical condition. Additional information was received by CCL on December 19, 2022, regarding staff not preventing the same resident from wandering away from facility on another date. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated July 7, 2022, R1 is diagnosed with mild cognitive impairment, is confused and disoriented, does not require continuous care, cannot leave facility unassisted and has wandering behavior. UnsubstantiatedRead the full finding— CDSS inspection report, February 27, 2023 · control 08-AS-20220613103313

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint investigation visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Wellness Coordinator Jenna Purnell. The Department’s investigation consisted of interviews with staff, residents, and outside sources, records review, and a tour of the facility. It was alleged that staff did not protect resident resulting in fractured ribs and the Licensee did not report resident’s change in condition to their responsible party. Review of resident 1’s (R1) medical records revealed that R1 was non-ambulatory, required a walker, had a diagnosis of dementia with behavioral disturbance and agitation, and had a history of confusion, disorientation, and aggressive behaviors. Interviews revealed that on October 30, 2021 at around 12:00am, Staff 1 (S1) heard R1 and resident 2 (R2) verbally arguing requiring staff to redirect both reRead the full finding— CDSS inspection report, November 21, 2022 · control 08-AS-20211101095744

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Kandy Franklin, Executive Director, to whom LPA disclosed the reason for the visit. Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of a tour of the facility, review of facility and outside source records, and interviews of staff and outside sources. It was reported to Community Care Licensing that Resident 1 (R1) [LIC 811 Confidential Names List was provided to identify the resident] fell out of his/her wheelchair in the facility, hit his/her head, and was found on the floor, but facility staff did not seek timely medical attention for R1. Based upon information reviewed during the investigation, R1, who was a resident receiving hospice services, UnsubstantiatedRead the full finding— CDSS inspection report, September 28, 2022 · control 08-AS-20200716113029

Licensing Program Analyst (LPA) Kennedy conducted an unannounced Complaint Visit to investigate the above allegations. LPA met with Kandy Franklin, Administrator and discussed the purpose of the visit. LPA conducted a tour of the facility accompanied by Paula McKnight, Maintenance Supervisor, requested records, and interacted with clients in care. The LPA observed a general state of uncleanliness throughout the facility including substances on the floor rending the floors sticky, toilets with feces on them, bugs in some living area, floors in living areas, bathrooms and showers that are stained and have solid and/or liquid waste on them. Based on these observations these allegations are substantiated. A substantiated finding means the allegations are valid because the preponderance of the evidence standard has been met. SubstantiatedRead the full finding— CDSS inspection report, July 14, 2021 · control 08-AS-20210712083444