complaint·December 29, 2025

Regarding the allegation: Staff do not administer medication(s) to resident in care as prescribed by their physician. It is being alleged that resident #1 (R1) did not receive their prescribed medications. LPA asked for R1's MAR-Medication Administration Record and or centralized stored medication form and two (2) staff stated, "they do no keep a MAR and/or centralized stored medication form for any of the residents." Although, LPA interviewed (3) three residents that confirmed their medication is being provided to them everyday, the medication they receive is not being documented and there is no list of medication being received. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. Regarding the allegation: Resident developed bed sores due to staff neglect. It is being alleged that resident #1 (R1) developed bed sores due to staff being neglectful. During LPA’s interview with staff two (2) staff confirmed that R1 needed a lot of help. One (1) staff member confirmed that R1 just wanted to stay in bed and R1 was also difficult to lift. During LPA’s interview with two (2) witnesses they confirmed that R1 had obtained wounds at the facility. Both witnesses did not know what stage the wounds were. During LPA’s record review it was determined that R1 was not under the care of home health and/or hospice for wound care. In addition, R1's pre-placement appraisal, physician's report and Appraisal/Needs and Services Plan did not indicate that R1 had any bed sores/wounds at the time of admission. Let it be noted, R1's admission was on 08/05/2025. The facility did not update and/or do a resident appraisal indicating that R1 was developing a wound and R1 was not sent to the hospital. LPA requested medical records from Kaiser Permanente, and it was determined that R1 was admitted on 09/23/25 at the hospital and had one (1) wound and a deep tissue injury- the wound was on the coccyx of R1 stageable as two (2) and the deep tissue injury was on the right heel of R1’s foot. Therefore, based on the medical records and interviews conducted the allegation is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, a civil penalty issued, appeal rights and a copy of this report was given to the Administrator. Regarding the allegation: Staff yell at resident in care. It is being alleged that the staff have yelled at resident #1 (R1). LPA interviewed three (3) residents that confirmed staff have never yelled at them. During LPA’s interview with two (2) staff confirmed that they have never yelled at any of the residents. LPA also interviewed R1's sister that confirmed the staff at the above facility are super nice. During LPA’s physical tour, LPA did not witness any staff yelling at the residents. Therefore, based on the observations and interviews conducted the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.