complaint·September 10, 2025

LIC 9099-C Allegation: Staff did not update resident's medical records. The department conducted extensive interviews regarding the allegation cited above. An interview conducted with the reporting party revealed that R1 has been switched from Kaiser Permanente to Mercy Health effective January 1, 2025, which the facility was notified and provided with an updated medical card. An interview conducted with the Health and Wellness Director on March 7, 2025, revealed that the resident (R1) was sent out to Kaiser Permanente Roseville for evaluation due to leg pain. The Health and Wellness Director stated a new medical card was provided; however, it was not updated on the chart, therefore, R1 was sent to the wrong medical facility for evaluation. Based on R1’s identification and emergency information, it revealed that R1’s hospital to be taken in an emergency was previously written as “Kaiser Roseville” and then crossed out with new input of “Mercy Folsom”. File review of hospital discharge paperwork and progress notes revealed that R1 was sent out to Kaiser Roseville for evaluation. Based on the information obtained, the allegation is SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Please see LIC9099-D. Exit interview conducted, copy of report and appeal rights was provided. LIC9099-C Allegation: Staff did not provide adequate supervision resulting in resident falling. Based on file review of resident’s (R1) progress notes, it revealed that R1 was transported to the emergency room for evaluation due to leg pain. No further indication of a fall. An interview conducted with R1’s responsible party revealed that facility staff have alleged two separate statements that R1 had a fall while in the shower; however, also being informed that R1 did not have any fall in the shower. The interview conducted with Health and Wellness Director on March 7, 2025, revealed that R1 has showering assist getting in and out of the shower, but there is no reporting of R1 sustaining a fall in the shower. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint 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. Exit interview with administrator . LIC 9099-C Allegation: Facility AC/Heater wall unit is in disrepair and accessible to residents. On February 25, 2025 the Department received the complaint with the allegation cited above. On March 7, 2025, the Department conducted an inspection of the facility's air conditioning unit located at the end of the common area. Based on observation, the air conditioning unit was operating and in good condition. There was no observation of the air conditioning unit being a danger to residents in care. Allegation: Staff did not seek medical attention to resident. Based on file review of the resident’s (R1) progress notes, it revealed that R1 was experiencing pain at approximately 4:30 AM and was given PRN medication. Approximately an hour later, R1 continued to express leg pain which facility then contacted emergency medical services. File review of R1’s hospital discharge paperwork revealed X-rays were taken and found to be normal and discharged at approximately 12:52 PM. Allegation: Staff did not notify resident's responsible party of incident. Based on file review of the resident’s (R1) progress notes documented by medication technical, it revealed that R1 was experiencing pain at approximately 4:30 AM and was given PRN medication was administered. Follow up notes revealed R1 continued to express pain which facility then contacted emergency medical services, and then notified Health and Wellness Director and R1’s responsible party. Based on the information above, the department concluded that the allegations are unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, and a copy of the report was provided.