complaint·August 24, 2025

In regard to the allegation” Staff did not answer resident's calls for assistance timely resulting in hospitalization”, It is alleged that staff failed to assist R1’s call for help from the pull cord resulting in R1 having to call 911 for themselves. During interview with Administrator, and staff five (5) out of six (6) stated that R1 pulled his/her pull cord and staff responded by knocking on R1’s door but did not enter room in fear of being yelled at by resident and not until paramedics arriving did, they know that R1 was having an emergency. During interviews with residents six (6) out of six (6) stated that staff may enter their room in case of an emergency with no problem. R1 stated that pull cord was used repeatedly and no staff came to assist resulting in 911 being called. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Administrator. In regard to the allegation “Staff did not notice residents change in condition”, it is alleged that staff failed to follow up on R1’s change of condition. During interviews with Administrator and staff six (6) out of six (6) stated that if staff notices a change of condition, it is reported immediately, and resident is observed. During document review it was revealed that R1’s vital signs and oxygen was checked and documented and R1 stated that they were feeling okay. During interviews with residents six (6) out of six (6) residents stated that if staff notices any changes they will come and check on them. R1 stated that med-tech checked on him/her and that they honestly felt better. In regard to the allegation “Due to staff neglect, resident missed medications”, it is alleged that resident missed two medications due to staff neglect During interviews with Administrator and staff six (6) out of six (6) stated that all medications are given as prescribed. Administrator stated that R1 is in charge of their own medications and the facility does not hold medication for this particular resident however they provided medication services until R1 was feeling better. During that time staff noticed that at time of discharge from hospital R1 was given two new medications that R1 never picked up from pharmacy. During interviews with residents six (6) out of six (6) residents stated that they have never had any problems with medication at the facility. R1 stated that they are in charge of their own medications but did ask for assistance for a few days after hospital stay in which facility did provide. In regard to the allegation “Staff did not follow Physicians orders”, it is alleged that staff gave resident a full dose of medication instead of half as prescribed. During interviews with Administrator and staff six (6) out of six (6) stated that medication is always given as prescribed. During interviews with residents two (2) out of six (6) residents stated that staff follows directions for all medications. Four (4) residents stated they don’t need help with medication management from staff. In regard to the allegation “Due to staff neglect, resident was not provided meals”, it is alleged that staff failed to feed R1 upon return from hospital. During interviews with Administrator and staff six (6) out of six (6) stated that residents can always ask for meals if they are hungry. Administrator stated that R1 returned late from hospital and did not ask for a meal as a courtesy facility put R1 on tray service free of charge for three days. LPA obtained copy of meal service plan. During interviews with residents six (6) out of six (6) residents stated that they are always provided meals. R1 stated that he was feed dinner at hospital and upon return he/she was too tired to eat. R1 also stated that facility did provide tray services for three days. In regard to the allegation “Due to staff neglect, staff did not check on resident”, it is alleged that staff did not know R1 had returned from hospital and did not check on R1. During interviews with Administrator and staff six (6) out of six (6) stated that anyone entering the facility needs to be checked in. Administrator stated there were notes that R1 returned in the evening and staff did check on R1. During interviews with residents four (4) out of six (6) residents stated that they have never retuned via ambulance. R1 stated that two staff checked on him/her the night they returned from hospital. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. 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 allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided.