complaint·January 13, 2026

This assessment was signed by facility personnel only. LPA observed outside agency progress notes for R1 dated June 7, 2023 to July 24, 2023 from Kaiser home health personnel to provide stage 2 wound care on R1s coccyx . LPA observed home health personnel to notate the wound to be a stage 3 pressure wound on June 16, 2023 with notes of instruction to staff on ADLs with no other changes. LPA observed notations of no new wounds or significant changes for R1 throughout the home health personnel documents. LPA observed notations on July 7, 2023, noting instructions for facility staff and that the wound is improving. On July 12, 2023 home health personnel noted that R1 was improving with positive skin growth to the wound. LPA observed notations from home health personnel that R1s wound had healed and wound care was to be discontinued on July 24, 2023. LPA did not observe home health documents from April of 2023 due to the facility not having the documents. LPA interviewed staff regarding R1s pressure wound and three of five staff could not recall or did not know about R1s pressure wound. One of five staff remembered a home health agency coming to the facility for R1 but could not recall why. One of five staff informed LPA that they remembered R1 having bed sores but could not recall if R1 received home health services due to the pressure wound. The Department interviewed staff in September of 2023 that stated R1 received all their medications even if they had to dispense the medication themselves. LPA interviewed five staff regarding R1s medication administration and five of five staff could not recall or did not know about R1s medications. One of five staff informed LPA that they did not dispense medications to R1 due to not having to dispense any medications during the night shift. Two of five staff informed LPA that they do not dispense medications to residents in care. LPA observed current client medications and observed that they were being given as prescribed. LPA interviewed three of three residents in care and was informed that they receive all their medications as prescribed with no issues. LPA was unable to interview R1 due to not being at the facility anymore. Although it was alleged that staff did not prevent a resident from developing a pressure injury, LPA was unable to review all home health records due to the facility not retaining resident documentation from April of 2023 along with facility notes pertaining to needs and services provided by the facility and the progression of R1s wounds. This allegation has been deemed UNSUBSTANTIATED. Continue on LIC9099C Although it was alleged that staff did not administer medication to a resident in care LPA was unable to review R1s physicians orders or medication administration record due to the facility not retaining resident documentation. This allegation has been deemed UNSUBSTANTIATED. Based on information gathered, interviews and record review, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred: Therefore, the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was left at the facility.