complaint·December 5, 2025

The investigation revealed the following: Regarding allegation: Staff did not provide medical attention to resident as needed. It is alleged R1 was in pain and medical assistance was not obtained. Interviews with 6 out of 6 residents stated facility staff assist them with obtaining medical care when needed. Interview with staff revealed 5 out of 5 staff stated that staff provide assistance to residents as soon as they require it. Per administrator and facility’s nurse, on 7/24/25 facility’s nurse provided pain medication to R1 once R1 complained of pain. Per facility’s nurse, R1 often has pain due to health-related conditions. Therefore, the plan is to provide pain medication as prescribed by physician. As soon as R1 continue to complain of pain, facility staff send the resident out to the hospital. Documents reviewed revealed, Home Health Visit notes dated 8/6/25, note R1 is to be provided Norco for pain as needed. Per July 2025 medication sheet, on 7/24/25 R1 was provided morning dose of Hydroco/APAP for pain, no additional doses were provided as R1 went out to the hospital. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Staff did not follow resident’s care plan. It is alleged R1 required catheter care and facility staff did not provided. Interviews with residents revealed 6 out of 6 residents stated facility follows care plan or assist with care as needed. Interviews with staff revealed 5 out of 5 staff stated they follow resident’s care plan, which is explained by the administrator to the caregivers. Documents reviewed revealed Home Health Notes dated 7/23/25, note R1 was provided care for foley catheter by home health nurse and will continue to provide care and consult with physician regarding care. July 2025 medication sheet, notes R1 was being provided with antibiotics from 7/21/25-7/24/25. Home Health After Visit Summary notes R1 was at the hospital between 7/24/25-7/28/25 changes to antibiotics were noted. Although R1 had a change in condition, facility staff were following R1’s home health agency plan of care and a nurse was providing care with catheter. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Jose De Leon and a copy of this report was provided.