complaint·July 14, 2025

The investigation revealed the following: Allegation: Staff did not address a resident's change in medical condition On 7/14/25, LPA Felisa Shirley reviewed R1’s Admission Agreement and observed that R1 moved into the facility listed above on 5/4/25. LPA Shirley reviewed R1’s Physician report, dated 5/8/25. During record review, LPA observed that R1 was non-ambulatory due to both physical and mental conditions. LPA Shirley observed the section, Physical Health status for Motor Impairment/Paralysis and saw that due to R1’s gait instability a walker was ordered on 5/8/25. LPA Shirley reviewed the Resident Appraisal for R1 and observed the Physical Disabilities section and it stated that a front wheel walker was ordered due to balance issues. During file review, LPA Shirley observed that R1 had a check-up on 5/19/25. During the check-up, Kaiser Home Health for Physical Therapy was ordered. LPA interviewed staff, staff 1 – staff 6 (S-1 – S-6). LPA asked, does staff address residents change in medical conditions while in care. Of those interviewed 6 out of 6 stated yes. LPA interviewed resident 1 – resident 3 (R-1 – R-3). LPA asked residents, does staff address your changes in medical conditions while in care. Of those interviewed, 2 out of 3 answered yes, and 1 answered no. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Con'd on 9099-C Allegation: Staff did not prevent a resident from being hit while in care On 7/14/25 LPA Felisa Shirley reviewed R1’s Preplacement Appraisal, dated 5/5/25. Upon review, LPA observed that R1 has difficulty communicating due to memory issues from dementia. LPA Shirley reviewed R1’s Physician’s Report dated, 5/8/25. During record review LPA Shirley observed that R1 was diagnosed as having dementia. During interviews, LPA Shirley ask R1 has anyone hit her while in care and R1 answered no. LPA interviewed staff, staff 1 – staff 6 (S-1 – S-6). LPA asked, does staff prevent residents from being hit while in care. Of those interviewed 6 out of 6 stated yes. LPA interviewed resident 1 – resident 3 (R-1 – R-3). LPA asked residents, does staff prevent residents from being hit while in care. Of those interviewed, 3 out of 3 answered yes. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to Elvira Brondial.