Complaint·December 17, 2025

The investigation into the allegation, facility staff failed to report a fall incident to a resident's reporting party in a timely manner, revealed the following. It was reported that in September 2023, R1 suffered a fall and the responsible party was not notified in a timely manner. No specific date was provided for R1's fall. The Administrator reported that R1 did have a fall in September 2023 but could not remember the exact date. Staff 1 reported that R1 started to fall out of their wheelchair and Staff 1 broke their fall but R1 still bumped their head on the ground. At that time R1's hospice nurse was present and assessed R1. R1's hospice nurse assessed R1 and determined R1 did not need emergency services. First aid was applied and R1 was taken to her room. R1' hospice nurse verified this information. The Administrator reported they contacted R1's responsible party and reported the incident. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, facility staff failed to notify a resident's responsible party of a change in condition requiring an admission onto hospice care, revealed the following. Resident 1 (R1) moved into the facility May 15, 2023 and moved out November 30, 2023. A review of records shows R1 was put on hospice on September 9, 2023. The Administrator reported that R1 appeared to be losing weight and wanted R1 to be evaluated by hospice. The Administrator reported that R1 agreed. The Administrator reported that they informed the responsible party and they agreed. R1 was assessed and hospice was approved. R1 was admitted to hospice for unspecified protein/calorie malnutrition. The Administrator reported that the responsible party was notified and kept informed of all of R1's changes. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, facility staff did not provide a responsible party with a list of the prescribed medication for a resident, revealed the following. It was reported that after R1 moved out the responsible party requested a list of medications for R1. It was reported that the facility was taking R1 to medical appointments without notifying the responsible party. The Administrator reported that R1's appointments were at the facility and the responsible party was notified about each appointment. 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. The Administrator reported that any issues with medication should have been communicated with the physician because the facility only administers medications as prescribed and doesn't decide what medications are prescribed. The Administrator reported that the responsible party was provided with R1's medications and a list of their medications when R1 moved out. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.