complaint·August 14, 2025

The investigation revealed the following: Allegation: Staff did not address a resident's change in medical condition It is alleged that R1 was able to walk prior to her admission to this facility, had weight loss and staff did not address the changes. A review of R1’s admission agreement, LPA Felisa Shirley observed that R1 moved into the facility listed above on 5/4/25. On 5/4/25, per the facility’s client weight record, R1 weighed 104.8lbs. Per Kaiser’s medical assessment dated, 5/8/25, the doctor recorded a history of R1’s weight fluctuation from 7/12/23 (112lb 3.4oz), 4/15/24 (112lb 7oz), thru 5/8/25 (107 lb 5.8oz). R1 was non-ambulatory due to both physical and mental conditions per Physician report, dated 5/8/25. 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 that check-up, Kaiser Home Health ordered physical therapy. LPA interviewed staff, staff 1 – staff 6 (S-1 – S-6). Of those interviewed, 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 3 (R-1 – R-3). Of those interviewed, 2 out of 3 denied the allegation. 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 It is alleged that R1 was hit while in care. During interviews, LPA Shirley interviewed the Administrator and was told that there is no history of elder abuse and no reports of abuse. 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. Per interview with the Administrator, R1 was confused a lot and frequently call out for persons not there. Per Appraisal/Needs and Services dated 5/4/25, R1 can’t verbalize her needs due to memory issues. LPA spoke to W1 and was told that R1’s base prior to being admitted to this facility was confusion and didn’t always recognized family members. LPA interviewed staff, staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 3 (R-1 – R-3). Of those interviewed, 3 out of 3 denied the allegation. 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.