Complaint·May 16, 2025

Record reviews of the medication administration record (MAR) reveal that a doctor's order had been placed for the medication in question (M1) on September 5th, 2024 (09/05/2024). Though M1 is to be provided once per week (1x/week), M1 had been marked as having been administered to a resident nineteen (19) times during the month of September (09/2024). The MAR, following M1, indicates that a resident's Dr.'s order had been followed between the dates of 10/25/2024 through 11/07/2024. M1 was provided to the resident on November the eighth, 2024 (11/08/2024) and November the fifteenth, 2024 (11/15/2024), again following a resident's Dr. order, yet no more administration marks had been placed on the MAR during the month of November (11/2024). Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D. One deficiency has been cited during today's visit, please see LIC9099-D. An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights, this deficiency and this report have been provided. The investigation revealed the following: Regarding the allegation, "Resident developed a pressure injury due to staff neglect". It has been alleged that a resident has not been rotated as often as needed. Although the facility does not keep a rotation log for the residents requiring this service, LPA interviews revealed that nine (9) out of fourteen (14) residents and all six (6) staff interviewed, out of one-hundred and five (105) staff, have not agreed with the allegation. Record reviews revealed that a resident did have a stage two (2) pressure injury, but on November nineteenth, 2024 (11/19/24) the same resident requested discharge from their home-health services provided by Excel Home Health in order to choose an alternate service(s) which are also related to a resident's health condition. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violation did occur. Therefore, the above allegation is found to be Unsubstantiated . There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Suzette Johnson, Executive Director, and a copy of appeal rights and this report have been provided.