complaint·February 21, 2026

Regarding the allegation that lack of incontinence care resulted in a skin condition for Resident #1, the investigation revealed sufficient evidence to support the allegation. According to hospice progress notes and interviews, Resident #1 was frequently observed saturated with urine and feces, including bedding and clothing, upon hospice arrival. Staff reported providing incontinence care every three hours and as needed; however, hospice documentation indicated that such care was not consistently provided per the care plan. Hospice staff documented repeated education to facility caregivers on the importance of incontinence checks and timely care. Despite this, there was no record of compliance monitoring or corrective documentation by the facility to ensure staff followed the plan of care. Based on hospice records, interviews, and facility documentation, the preponderance of evidence demonstrates that the facility failed to provide consistent incontinence care, which contributed to further skin deterioration and discomfort. Therefore, the allegation is SUBSTANTIATED. Regarding the allegation that medication was not issued as prescribed, the investigation revealed sufficient evidence to support the allegation. During the 10-day visit conducted on 02/26/2025, two medication pills were observed on the floor next to Resident #1’s bed. Hospice nursing staff also reported missing Morphine tablets that were not documented on the MAR, and confirmed that staff had been educated multiple times on controlled-substance tracking. A caregiver stated that medications were occasionally crushed in ice cream to assist the resident with swallowing. Review of the physician’s report and medication orders revealed no authorization for crushing any medication. Based on observations, interviews, and record review, the preponderance of evidence demonstrated that the facility failed to ensure medications were administered and documented according to physician directions and hospice protocol. Therefore, the allegation is SUBSTANTIATED. The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted with Facility staff, Angelina Escobar , and appeal rights provided.