complaint·November 7, 2025

Allegation: Staff mismanaged resident’s medications Finding: Substantiated During investigation, LPA interviewed reporting party (RP), facility staff (ADM, S1) and reviewed resident’s (R4) documents. Review of R4’s admission agreement, centrally stored medication logs and medication administration records showed he was first admitted at the facility on 09/11/25 coming from a skilled nursing facility (SNF). On 09/16/25, staff informed R4 that his prescribed medication had run out. Staff (ADM, S1) confirmed with LPA that they failed to follow up with R4’s primary care physician on his prescription refill requirements. Based on interviews and observations which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that staff mismanaged resident’s medications is substantiated. Allegation: Staff did not attend to resident’s call for help Finding: Substantiated During investigation, LPA interviewed reporting party (RP/ Ombudsman (OMB)), facility staff (ADM, S1) and residents (R1, R2). On 09/17/25, RP/Ombudsman witnessed a resident (R1) in Room #207 shouting for help at 3:10PM. RP/OMB informed housekeeping who was cleaning a room on the 2 nd floor who called the front desk for help with no staff response. At 3:53PM, RP/OMB informed staff on the 1 st floor that R1 needed assistance. RP/OMB stated staff finally arrived around 3:55PM and helped R1. On 09/24/25, ADM confirmed with LPA that residents do not have a call button device available to alert staff for assistance when needed. Based on interviews and observations which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that staff did not attend to resident’s call for help is substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal rights and a copy of this report provided . Allegation: Staff left residents in soaked bedding Finding: Unsubstantiated During investigation, LPA interviewed reporting party (RP), staff (ED, S1, S2), random residents (R1, R2, R3, R4) and reviewed residents’ documents. Staff (ADM, S1, S2) denied leaving residents in soaked or soiled bedding. S1 stated staff conducts daily care rounds per shift to assist residents with toileting, showering, changing diapers/linens/clothing as needed. Review of residents’ weekly incontinence records dated 08/01/25 until 10/31/25 showed staff provided assistance with residents’ ADLs which included assisting with incontinence care (3X to 4 X per day or as needed), changing wet linens/beddings, toileting, transferring, showering, dressing, grooming, medications, meals and doctors’ appointments. During unannounced visits on 07/03/25 and 08/11/25, LPA observed residents to be clean, well-groomed, odor free and comfortable in their surroundings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation that staff do not ensure that resident’s incontinence needs are met is unsubstantiated Exit interview conducted and a copy of this report provided.