complaint·November 3, 2025

During interviews, R1 reported receiving daily personal hygiene assistance from staff. Additional interviews with other ten (10) residents confirmed that they had consistently received all necessary hygiene care from facility staff. Furthermore, interviews with three (3) staff members supported the residents’ accounts. A review of R1’s care plan also aligned with R1’s statement, indicating that hygiene care had been provided as agreed. Based on the record review and interviews conducted, there is insufficient evidence to support the allegation that staff are not meeting resident's personal hygiene needs. Therefore, the allegation is unsubstantiated . It was alleged that staff are not safeguarding residents personal property. According to the information received, several items from R1’s room were missing. LPA conducted an interview with R1, who stated they did not know if any personal items were missing from their room. LPA conducted additional interviews with other ten (10) residents, all of whom denied experiencing any personal items stolen from their rooms. LPA conducted an interview with Staff #1 (S1), who stated they have not received any reports of missing or stolen items from R1 or their representative. LPA conducted interviews with two (2) other staff members, all of whom denied any knowledge of R1’s missing personal items. Based on the record review and interviews conducted, there is insufficient evidence to support the allegation that staff are not safeguarding residents personal property. This allegation is unsubstantiated . It was alleged that staff do not ensure an appropriately skilled professional is performing catheter care. According to the information received, R1 has a Foley catheter, and no one at the facility is qualified to provide care for the catheter as the authorization for home health nurses to assist R1 with the catheter had expired. LPA’s record review revealed R1 required use of Foley catheter. LPA conducted an interview with R1, who stated they did not have any problem with their catheter. LPA conducted an interview with S1, who stated that R1 has been receiving catheter care from their home health nurses. S1 added that the facility staff do not provide catheter care for any residents as it is a responsibility for trained professionals. LPA conducted an interview with a case manager (CM) from R1’s home health agency, who stated that there has been no issue with providing care for R1’s catheter. CM added that there is no such thing as expiration of catheter service authorization. Continued on LIC9099-C.... Based on record review and interviews conducted, there is insufficient evidence to support the allegation that staff do not ensure an appropriately skilled professional is performing catheter care. This allegation is unsubstantiated . It was alleged that staff changed resident’s primary doctor without POA’s consent. According to the information received, R1’s primary doctor has been changed frequently without the POA’s consent. LPA’s record review revealed that R1 was admitted to the facility in October 2024 from a skilled nursing facility in Banning, California. Upon transfer to this facility, R1 was transferred to RUHS healthcare network which provided R1 with a new primary physician who is within the healthcare network. LPA conducted an interview with S1, who stated R1’s primary physician was selected either by R1’s POA or assigned by the healthcare network. S1 added that all residents, including R1, arrive with documentation showing their healthcare network and primary physician. S1 stressed that no facility staff can change or participate in selecting residents’ primary physician. LPA’s record review revealed that R1 has had the same primary physician since their admission in October 2024. Based on record review and interview conducted, there is insufficient evidence to support the allegation that staff changed resident’s primary doctor without POA’s consent. This allegation is unsubstantiated . It was alleged that staff do not dispense resident their prescribed medication. LPA conducted an interview with the relevant party (RP) associated with R1, who stated that they were not sure what medication the staff are dispensing to R1. RP was unable to provide any additional information. To further investigate, LPA interviewed Staff #3 (S3), who asserted that all residents had received their prescribed medications without any omissions. S3 supported this claim by presenting records from the facility’s electronic medication administration system. Additionally, LPA conducted a medication count of R1’s inventory, which aligned with the documentation and confirmed S3’s statement. Based on the observations made and interviews conducted, there is insufficient evidence to support the allegation that staff do not dispense resident their prescribed medication. This allegation is unsubstantiated . A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.