complaint·January 7, 2026

The Administrator and Assistant Administrator reported the medication was administered but not marked in the Medication Administration Record (MAR). The Administrator reported that R1 was seen regularly by her physician and home health nurse. R1 was seen by her primary care physician (PCP) on July 18, 2024, August 15, 2024, September 19, 2024 and October 17, 2024. The Administrator reported that R1 was never sent out to the hospital during their stay at the facility. 4 out of 4 caregivers reported they did not observe any health related issues with R1 during their stay at the facility. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights. LPA observed the list in the kitchen. 2 out of 2 kitchen servers and the head chef reported that R1 was not served food high in sugar or inappropriate for a diabetic. It was reported that starches, sugary food and food not appropriate for a diabetic were served to R1. It was reported that staff reported to R1's responsible party that R1's glucose level was above 400. No specific dates or times were provided when the inappropriate food was provided or when staff informed the responsible party R1's glucose was above 400. 4 out of 4 caregivers interviewed denied the reports. R1's home health nurse could not corroborate the reports. R1 received home health visits from a nurse daily. LPA reviewed the facility's menu, the facility menu meets title 22 requirements. No incidents were reported involving R1 going to the hospital for any reason. The Administrator reported that R1 was never sent to the hospital while living at the facility. LPA attempted to interview R1 but they did not respond to any questions. None of the evidence gathered supports the allegation, therefore the allegation is unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff does not ensure hygiene needs are being met resulting in resident developing infections, revealed the following. It was reported that R1 had multiple urinary tract infections (UTIs) while at the facility and an infection on the abdomen. The Administrator reported that R1's hygiene needs were met and R1 had never been diagnosed with a UTI. R1's physician ordered a urinalysis on August 13, 2024 and on October 17, 2024. R1 had a doctor's visits on August 15, 2024 and on October 17, 2024. Facility records verified this information. The Administrator reported that R1's responsible party requested that R1 be put on an antibiotics prior to the urinalysis being completed in August and October. A review of R1's medicaiton administration record shows R1 was prescribed antibiotics on August 13, 2024 and October 18, 2024. The results of both tests were inconclusive, suggesting both samples were contaminated. The Administrator reported that since R1 was already prescribed and taking antibiotics at the request of the responsible party, R1's physician did not order new tests. The Administrator reported that R1 moved in with redness on their abdomen and the Clotrimazole 1% topical cream was listed on their original physician's report medication list dated May 8, 2024. A review of R1's physician's report verified this information. R1's MAR for July 2024 shows R1 was prescribed Clotrimazole 1% topical cream from July 5 to August 6, 2024. R1's home health nurse reported R1's hygiene needs were being met by staff and stated R1's possible UTI's and redness on the abdomen could not be attributed to lack of care. R1 received home health visits daily. 4 out of 4 caregivers interviewed reported R1's hygiene needs were always met. R1's responsible party did not respond to LPA's request for an interview. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff leaves resident soiled for extended periods of time, revealed the following. It was reported that R1's briefs were not changed timely and R1 was left in soiled briefs for an extended period of time. No dates or times were provided as to when this incident took place. 4 out of 4 caregivers interviewed denied the allegation and reported that R1's incontinence needs were always met. R1's home health nurse reported that they visited R1 at least 5 days a week and R1 was always clean. R1's home health nurse reported that they did not observe any issues with R1's hygiene. The Administrator reported that R1 was well cared for and they always communicated with the responsible party regarding R1's status. R1's responsible party did not respond to LPA's request for an interview. Based on the evidence gathered the allegation is unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.