complaint·March 13, 2026

Record review of R1’s emergency contact form from 11/18/23 and Medication Administration Record (MAR) from March 2025 indicated R1’s physician was Dr. Hove. Record review of an email from 06/05/24 from R1’s responsible person (F1) showed R1 had a new physician. Additionally, interview with F1 at 5:10 p.m. on 05/13/25 revealed they informed the facility that Dr. Padilla was R1’s physician around that time. Record review of incident reports from 03/03/25, 03/24/25, 03/25/25, and 03/27/25 indicated the facility notified R1’s family of the incidents but not their physician. Interview with the Care Coordinator (S1) at 11:25 a.m. on 06/04/25 revealed they did not contact R1’s physician after their falls in the month of March, though R1 was hospitalized after expressing pain on 03/25/25. S1 also noted that staff did not mention any reports of R1’s pain to them on 03/26/25 or 03/27/25. Interview with the Marketing Director (S2) at 11:05 a.m. on 06/24/25 revealed when families set appointments for residents, the facility typically reports resident conditions and status changes to family members so they can report to the physician. Interview with the administrator at 3:05 p.m. on 06/24/25 revealed the facility did not update R1’s physician of their changes per the family’s request. Also, the family frequently changed R1’s physician. Interview with Dr. Mulroy at 10:15 a.m. on 07/01/25 confirmed R1 had four (04) physicians within the past few years. Based on interviews and record review, despite R1’s changes of physicians, the administrator and staff did not report changes of condition to R1’s physician. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the corresponding LIC 9099-D page. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided. Regarding the allegation "Staff mismanaged resident's medication" it was alleged Resident #1 (R1) did not receive antibiotics or pain medication to treat their Urinary Tract Infection (UTI) and resulting pain. Record review of R1’s physician report from 08/13/24 and reappraisal form 08/28/24 revealed the facility agreed to provide medication management assistance. Interview with R1’s responsible person (F1) at 3:00 p.m. on 05/30/25 indicated that all of R1’s prescriptions were given by Dr. Padilla and Dr. Hove. Physician’s orders from 03/25/25 revealed R1 was prescribed 300mg of the antibiotic Cefdinir to be taken twice daily for seven (07) days and Ibuprofen 400mg to be taken every six (06) hours as needed for pain. Review of the facility’s Medication Administration Record (MAR) from March revealed staff administered R1’s antibiotic twice daily as prescribed. LPA’s interview with the Care Coordinator (S1) at approximately 10:30 a.m. on 04/22/25 revealed R1 had taken all prescribed medications including their antibiotic. Investigator Santana’s interview with S1 at 11:25 a.m. on 06/04/25 revealed F1 wanted R1 to be provided with pain medication every six (06) hours. This was also confirmed in an email sent by F1 to the facility at approximately 5:15 p.m. on 03/26/25. S1 explained that the facility does not assist with PRN pain medication administration unless it is requested, and R1 had not requested it. R1 did not have physician orders for routine pain medications until 04/03/25. Interview with the Marketing Director (S2) at 11:05 a.m. on 06/24/25 revealed S1 offered pain medication to R1, but R1 refused the medication. Based on interviews and record review, the facility followed all physician orders for R1’s antibiotics, and R1 refused pain medication. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not provide incident report to resident's authorized representative" it was alleged a written report was not provided to R1’s representative. Record Review of R1’s emergency contact form revealed F1 was their authorized representative. Record review of incident reports revealed the facility verbally notified F1 of all incidents in the month of March 2025. R1 was hospitalized with a Urinary Tract Infection (UTI) on 03/25/25. At approximately 5:44 p.m. on 03/25/25, S2 provided written notice of R1’s fall and hospitalization on 03/25/25 by email to F1. Interview with F1 at 8:35 p.m. on 04/28/25 confirmed they received verbal reports of falls from 03/21/25, 03/24/25, 03/27/25. Based on observations, interviews, and record review, the facility notified R1’s representative of fall incidents verbally and of R1’s serious injury (UTI) in writing. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.