complaint·January 30, 2026

completed prior to move-in indicate that R1 bruises easily and required a high level of assistance. Four out of four facility staff interviewed stated that R1 had visible bruising prior to admission. Three staff reported observing R1’s private caregiver handling R1 roughly during transfers. Staff also reported observing the same private caregiver handle R1’s great-grandson, who has special needs, in a rough manner during visits to the facility. All staff interviewed stated they handled R1 with care, particularly due to frequent family monitoring. Two witnesses expressed concerns regarding R1’s care and believed R1 did not require a two-person assist; however, facility records and assessments completed prior to admission indicate R1 required extensive assistance. Witnesses interviewed corroborated that one staff member initially expressed discomfort assisting R1 alone and requested additional assistance, consistent with the documented care plan. Emergency department discharge paperwork from Kaiser indicates the treating physician believed R1’s elbow bruising and swelling were not related to infection or other emergent conditions and were most consistent with a minor injury expected to improve within two weeks. It was alleged that staff did not administer resident’s medication . Four out of four staff interviewed stated that R1 did not have complete or valid physician orders for several medications during their stay. Facility Progress Notes document multiple instances where medications brought in by the family or private caregiver did not match physician orders, including incorrect medication strength and missing orders. On January 22, 2025, records indicate that medication was delivered by the family without a corresponding physician order for essential medication, including Carbidopa/Levodopa for Parkinson’s disease. Progress notes reflect the facility made ongoing efforts to obtain appropriate physician orders, including attempts made up to R1’s move-out date of February 22, 2025. Documentation indicates the family was aware that physician orders were required for medication administration. Staff consistently stated they could not legally administer medication without a valid physician order and were required to follow Title 22 requirements. The Physician’s Report dated December 30, 2024, completed by a Physician Assistant, indicates medication (Complaint investigation continued on LIC9099C) management responsibilities were handled by R1’s private caregiver. The LPA also interviewed the Ombudsman, who attends resident council meetings and reported no known complaints regarding medication mismanagement at the facility. Resident interviews revealed varied experiences with medication management; however, these statements were general in nature and not specific to R1. Two residents reported satisfaction with medication services, and no residents provided information corroborating medication mismanagement related to R1. Therefore, based on documentation, medical evaluation, and consistent staff statements, there is insufficient evidence to conclude the bruising occurred as a result of facility staff actions or neglect. Based on documentation showing the absence of required physician orders, the facility’s documented efforts to obtain orders, and staff adherence to regulatory requirements, there is insufficient evidence to conclude the facility failed to administer medication improperly. The allegations mention above has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director John Goodwin. A copy of the report and confidential names list were provided to the facility.