complaint·December 18, 2025

(Continued from LIC 9099) On 12/07/2025 at 7:30am, R1 had an unwitnessed fall and was sent out to the hospital for assessment. R1 returned to the community at 2:30pm on 12/07/2025. Staff reviewed discharge paperwork and noted there were tests done at the hospital for an infectious disease. Staff immediately contacted the Wellness Director (WD) and WD instructed staff to set up Personal Protective Equipment in front of R1's apartment and to send R1 back out to the hospital. It was not confirmed if R1 had an infectious disease but the discharge paperwork noted that R1 was tested for infectious disease and was being treated with medication for infectious disease. R1 was sent out by non-emergency ambulance on 12/7/2025 at 5pm per Incident Report. R1 was in the community for two-and-a-half hours and remained in a shared room with a roommate. Per staff interviews, facility was not informed of any infectious disease for R1's return to the community. On 12/11/2025 the hospital social worker spoke with WD regarding R1's return and was told infectious disease test for R1 was pending. WD stated R1 could not return until the results of the testing were done. If R1's test confirmed positive for infectious disease, R1 would need to go to a Skilled Nursing Facility (SNF). If R1's test was negative, WD would go to the hospital for assessment and R1 would be able to return to the community. As of December 18, 2025 neither ED or WD received confirmation for test results but R1 has not returned to the community and currently resides in a SNF. WD provided LPA with documentation that R1's roommate's family were notified of possible exposure to infectious disease and will test resident to confirm. A staff in-service regarding Infectious Disease Protocol will be conducted on Tuesday, December 23, 2025 and will be submitted to the Department. Currently there are no cases of infectious disease reported and facility did not receive confirmation of diagnosis from hospital. LPA interviewed two of two staff who denied the allegation that Facility staff failed to address a resident's prohibited health condition adequately. When facility staff realized possible exposure to infectious disease, staff members initiated infection control protocol and sent resident back to the hospital for possible treatment. LPA interviewed three of three residents. Three of three residents did not have any knowledge of an infectious disease going around the community. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) LPA toured the community and observed residents watching television in the downstairs communal room, residents playing Bingo on the 2nd floor Activities Room and residents in the Library on the third floor. LPA did not observe any PPE stations in front of apartments, which would indicate a resident in isolation due to an infectious disease. Based on LPA's observations, record review and interviews the allegation that Facility staff failed to address a resident's prohibited health condition adequately is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Executive Director Carmen Galicia and a copy of this report was provided to the facility.