complaint·June 13, 2025

Regarding allegations - Licensee retained a resident with a higher level of care need, Staff do not ensure that resident is administered their correct medication(s), and Staff neglect resulting in resident developing recurring UTI's. It was reported that the facility has not been able to care for Resident #1 (R1) affectively – R1 is in a depressive episode, does not eat for days at a time. It was also reported that facility has given R1 the wrong medications (unknown what medication; date/time). In addition it was reported that R1 gets regular UTI’s leading to emergency room visits, which may have been avoided with proper care by staff. Interview with staff, R1 and records reviewed revealed that R1 is independent with all ADLs, facility manages R1’s medication and provides daily checks. Physician report dated 8/15/2024 indicates R1 is ambulatory, able to perform ADLs, able to leave facility unassisted, communicate needs, able to follow instruction, R1 is not confused/disoriented. Additional records reviewed confirmed R1 was hospitalized on 1/13/2025 and 2/2/2025, 3/17/2025 and 5/13/2025. R1 returned to the facility the same day following each hospitalization with no new orders; facility completed a needs and services plan following each hospitalization. Staff interviewed reported that R1 is coherent, able to make decisions, and manage own ADLs. Staff reported that if needed R1 is able to alert staff for any assistance with ADLs. R1 confirmed that if needed staff are there to assist with ADLs. Staff reported that currently R1 is appropriate for the facility and does not require higher level of care; R1 is monitored every 2 hours since discharge from hospital. No issues reported by R1. Regarding R1’s medication R1 did not report any issues with receiving medication; did not recall any errors. Staff reported that R1 receives medications daily with no noted errors/issues. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations “Licensee retained a resident with a higher level of care need, Staff do not ensure that resident is administered their correct medication(s), and Staff neglect resulting in resident developing recurring UTI's” is deemed unsubstantiated this time. Regarding allegations – “Staff do not ensure that resident attends their medical appointments as necessary”: It was reported that facility has not been able to keep up with R1’s medical needs and medical appointments in the past, despite agreement with these tasks. Information was provided that R1 was seen at Kaiser geriatric clinic on 2/18/2025 and was driven there by facility driver. R1 wandered off for about 15 minutes before being found. Interview with staff and records reviewed revealed that R1 is able to manage own medical appointments with the assistants of family and if needed facility staff. According to staff R1 is independent and manages own ADLs; family also is assisting with arranging medical appointment for R1. Facility staff reported that when needed facility staff also assists R1 with these tasks. R1 did not report any issues regarding staff assistance. Attempts made to reach R1's family on 3/13/2025; 4/22/2025, and 05/21/2025 was unsuccessful. Regarding allegation “Facility has bed bugs”: Information was provided that R1’s room was invested with bedbugs a few years ago, and it’s believed that bed bugs have likely returned. On 02/05/2025, LPA Chochian conducted another complaint visit regarding issues with bed bugs. From 10am-11am, LPA and Administrator toured the facility and LPA interviewed ten (10) residents. Residents reported no bed bug activity. R1 denied any bed bug activity in room. Administrator provide records and invoices from Hydrogen Pest Control for the last three months confirming general pest and bed bug prevention treatment conducted. On 2/28/2025 and 05/21/2025, LPA conducted a total of eight random resident interviews, and all reported that at this time there is no issue; residents reported if they observe any bed bugs they reported to staff and management. Currently no issues of bed bugs was reported by residents interviewed. Based on the above information gathered, there is insufficient evidence to support the allegation; therefore, allegation "Facility has bed bugs" is deemed unsubstantiated at this time. Exit interview held copy of report provided.