Complaint·March 23, 2026

An additional appointment on 07/25/2025 was also missed due to transportation issues and a scheduling conflict with R1’s neurologist appointment; no follow-up or rescheduling was conducted by the facility. Furthermore, R1 had an appointment on 08/25/2025, which was missed due to a change in R1’s condition, and no attempt was made by the Administrator Aliti to reschedule. Confirmation from the clinic indicated that there were no completed encounters or rescheduled appointments for these missed visits. Moreover, a review of R1’s external referral form dated 06/19/2025 revealed that R1 had stopped following up with their neurology provider, and now that the office is closed a new referral will be submitted. It was also learned that R1 was hospitalized on 11/06/2025 and discharged on 11/14/2025 with a change in condition, including a special diet of mechanical soft diet. A review of R1’s LIC 603A (Resident Appraisal) and LIC 625 (Needs and Services Plan) revealed that these documents were not updated to reflect R1’s change in condition. Additionally, it was learned that in the days leading up to hospitalization, R1 experienced a rapid and significant decline from baseline, including excessive mucus production resulting in choking episodes during sleep. Despite these symptoms, R1 was not promptly taken to the hospital or referred to a primary care provider, and this change in condition was not documented in facility records until addressed to Administrator Aliti on 01/05/2026. Per the Admission Agreement, the facility is responsible for regularly observing residents’ physical and mental conditions and arranging for incidental medical and dental care services; however, the facility did not meet these obligations. On 01/06/2026, Licensing Program Analysts (LPAs) Lee and Tamayo reviewed medications for three of ten residents by comparing medications on hand with Medication Administration Records (MARs) and identified discrepancies. MARs were not initial on multiple days, making it unclear whether medications were administered as prescribed or if staff did not document administration. Additionally, medications were not consistently administered in accordance with bubble pack instructions regarding dates and times. On 02/03/2026, LPAs Lee and Hughes reviewed Resident 2 (R2)’s MAR and observed missing initials for medication administration on 02/01/2026 and 02/02/2026. A review of R2’s medication, Amlodipine 10 mg (take one tablet by mouth daily), with a quantity of 30 tablets, and the Centrally Stored Medication Destruction Record (CSMDR), which indicated a start date of 11/05/2025, revealed discrepancies. Care staff Qadroka conducted a pill count and reported ten (10) tablets remaining, indicating inconsistencies in medication tracking. A review of R1’s MARs from October through January also showed discrepancies. CONTINUED LIC 9099-C MAR log for December 2025, shows some medications were documented as administered from 12/25/2025 to 12/27/2025 and some medications indicating that R1 did not get the medication since R1 was hospitalized during that time as well. Overall, the medication audit for R1 revealed multiple inconsistencies. Based on interviews, observations, and records reviewed during the investigation, LPA Lee was able to corroborate the allegations. As a result, these allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies were cited for two of the allegations: resident is being neglected by facility staff and facility does not ensure resident receives medications during a case management visit on 02/03/2026, therefore the findings are still substantiated and no citation for those two allegations will be given. However, the facility is being cited today for the allegation facility is not ensuring residents gets to doctors’ appointments. Citation is on LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Administrator, Aliti and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. Moreover, Facility staff acknowledged that the facility did not always maintain the required two-day supply of perishable food and seven-day supply of non-perishable food; however, staff stated that residents were not being deprived of meals. In addition, the facility was cited on 01/06/2026 for insufficient food supplies. During a prior facility visit on 01/05/2026, LPAs Lee and Tamayo toured the facility and observed seven (7) residents seated at the dining table eating breakfast. On 02/03/2026 facility visit, LPAs Lee and Hughes observed seven (7) residents eating breakfast, which included egg omelets, hash browns, toast, strawberries, blueberries, bananas, and coffee. Apples and oranges were also observed on the kitchen counter and available for resident access. Based on interviews and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided to the facility.