complaint·October 15, 2025

inhalation of secretions. Staff 1 reported they provided the DNR to the paramedics when they responded. Administrator stated the paramedics stated that R1 had to be transported to the hospital and R1’s family was upset that 911 had been called. Per Orange County Fire Authority Incident Report, there is no mention of DNR paperwork being provided and/or knowledge of R1’s DNR status. Records obtained from Saddleback Hospital, do not show that documentation of DNR was received by the paramedics. Hospital records document that the hospital became aware of DNR status from R1’s spouse who verbally advised them of R1’s DNR upon arriving at the hospital. Based on record review 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 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. Exit interview conducted and a copy of the report provided as well as appeal rights. Paramedics were able to get a pulse, and R1 was transferred to Saddleback Memorial Hospital where they subsequently passed on April 24, 2025. The cause of death was listed as Acute Respiratory Failure with Hypoxia and Pneumonia due to inhalation of secretions. Per Interview with Administrator, R1 would self-feed but due to their difficulty swallowing, R1’s food was always cut up in about .5 inches increments and was monitored by staff while eating. R1 could eat on their own but was very slow in the process. R1 did not want to be fed by staff and preferred to self-feed. Home Health notes showed R1 did not have food restrictions. Administrator a s well as staff stated R1 always had thick-it mixed in with fluids due to the risk of choking. Three out of three staff state R1’s food was always cut up and resident was monitored while eating. Although R1 did choke on food prepared, it remains unclear if choking was caused due to the food not being prepared properly. Regarding the allegation that staff force fed resident, the investigation revealed the following: Per pre-appraisal dated December 24, 2024, and physician report dated January 06, 2025, R1 was able to self-feed with staff cutting up the food. R1 was on soft food diet as well. Nursing notes indicated resident had no food restrictions. Three out of three staff deny force feeding R1 and state they were able to self-feed. Staff reported R1 would take a long time to eat and sometimes would fall asleep while eating but the staff stated allowing R1 the time to feed themself. R1’s family member would provide specific food for R1 and staff would allow the resident time to finish. R1’s family member indicated observing facility staff force the resident to eat. Regarding the allegation that Resident sustained skin tear while in care due to neglect, the investigation revealed the following: Per physician report dated January 06, 2025, R1 is diagnosed with Parkinson’s Disease and Dementia. Physician report shows R1 was admitted with a foot heel ulcer. Prior to R1 moving into the facility, R1 was seen on December 30, 2024, for a non-healing left heel ulcer initiated by a pressure injury and complicated by Dementia. R1 was seen at Saddleback Memorial Center for the condition. While admitted, R1 received wound care, in which the diagnosis was a Stage III. After selective debridement, the ulcer was then diagnosed as a Stage II at the time R1 was admitted to the facility. Resident was receiving wound care from Accent Care Home Health as well as Providence Palliative Care from December of 2024 through April of 2025. Nursing notes from Accent Home Health show that R1 was being seen for wound care to left and right heel ulcers approximately every seven days. Accent Home Health Notes showed instructions for elevating R1’s heels and that staff reported following instructions. The Administrator stated R1 had received a skin tear after R1 put their arm out as they were passing through a doorway. Home Health nursing notes show R1 was being treated for the skin tear as well. Although R1 did sustain a skin tear, it remains unclear if the skin tear was caused due to neglect. Regarding the allegation that staff unable to communicate with resident due to language barrier, the investigation revealed the following: Two out of two staff and two out of two residents deny any issues with communication. Two out of two residents state having no issues communicating with the staff even though English is a second language. Both residents state staff are attentive and communicative to their needs. Staff state being able to communicate with the residents without challenge. LPA interviewed both staff without any translation services. Staff 1 demonstrated knowledge of calling for emergency services and what information to provide. Regarding the allegation that staff not administering resident's medication as prescribed, the investigation revealed the following: S1 is primarily responsible for medication administration. S1 states providing R1's medication four times a day before meals as instructed in the physician order. LPA reviewed the medication order for Carbidopa and Levodopa for Parkinson's Disease four times a day at breakfast, lunch, dinner, and nighttime. Facility does not use a medication administration record for routine medications. Two out of two residents state knowing what their medications are and they are being administered per physician order. Based on records reviewed and interviews conducted, the department is unable to corroborate the above allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and copy of the report was provided to the facility.