complaint·October 27, 2025

(Continued from LIC9099) (page 2 of 3) It was alleged that staff are not ensuring that residents are administered their medication(s) as necessary. More specifically, it was alleged that staff failed to ensure that Resident #1(R1) received their prescribed medications. Staff interviews revealed that medications, including insulin and oral prescriptions, were offered per physician orders and that refusals were documented in the MAR. Staff acknowledged that the resident frequently declined insulin and blood glucose checks, and that he was informed of the risks associated with non-compliance. Resident interview confirmed that he often refused insulin because he did not like how it made him feel and did not always communicate this to staff. The resident’s representative stated that the resident reported missed doses but also acknowledged his tendency to refuse care. Records review revealed consistent documentation of medication refusals and a temporary supply issue on 5/7/24, which was addressed by staff using community supplies and contacting the pharmacy and POA. LPA observations confirmed that staff were aware of the resident’s medication regimen and followed procedures for offering and documenting care. It was also alleged staff are not ensuring that resident gets fed. More specifically, it was alleged that staff failed to ensure that R1 received meals as required. Staff interviews revealed that meals are served three times daily in the dining room and that residents are encouraged to attend. Staff stated that the resident occasionally declined meals due to personal preference or mood, but was always offered the opportunity to eat. Resident interview revealed that he sometimes chose not to eat because he did not want to be around others or was upset with staff. The resident’s representative stated that the resident reported missing meals but also acknowledged his tendency to isolate. Records review did not show consistent documentation of meal refusals or tray service, but there was no indication that meals were withheld. LPA observations confirmed that meals were being served during the visit and that residents were present in the dining area. Staff were observed offering meal options and encouraging participation. It was also alleged staff are forcing resident to stay in their room. More specifically, it was alleged that staff restricted R1 to his room. Staff interviews revealed that the resident was encouraged to remain in his room during periods of agitation or after altercations with peers. Resident interview revealed that he felt isolated and believed staff were intentionally keeping him in his room. Outside source interview confirmed that the resident reported being told not to leave his room. Records review showed documentation of one-to-one supervision and safety checks, but no formal room restriction orders. LPA observations revealed that the resident was in his room during the visit and stated he was told not to come out. (continued on LIC9099c) (Continued form LIC9099C) (Page 3 of 3) It was also alleged, the staff are preventing residents from participating in private visitations. More specifically, it was reported that R1 was not allowed to have private visits in his room with R2. Interviews with staff revealed that the Executive Director (ED) advised RP that R2 should not be in R1’s room due to safety concerns, but confirmed that staff did not physically prevent visitation. Staff #1 confirmed that R2 had been in R1’s room and that management had only discussed safety concerns with R1. R1 stated during the interview that he was frustrated about visitation limitations, but did not report being physically prevented from seeing R2. RP did not provide evidence that staff enforced a restriction. No outside sources provided information to support that visitation was restricted. A review of facility records revealed no documentation indicating that staff restricted or denied private visitation. Facility policies do not prohibit private visits in resident rooms. LPA observations confirmed that R1 was seen interacting with other residents and family members and had access to his room and outdoor areas It was also alleged, the staff are not responding to Resident's Representative's requests for communication in a timely manner . More specifically, R1 responsible person's inquiries were not being acknowledged or addressed by facility staff. Interviews with staff revealed that the assigned nurse did not recall specific interactions with R1 and denied receiving complaints. The ED stated that staff made efforts to coordinate care and respond to RP’s concerns. R1 reported during interview that he distrusted the assigned nurse and admitted to refusing insulin and other medications. The pharmacy confirmed that R1 had a prescription for insulin but no refills and that they had contacted the listed physician without response. A review of records showed that insulin and diabetic supplies were available, refusals were documented in the Medication Administration Record (MAR), and staff used community supplies when insurance issues arose. Communication logs reflected multiple contacts with RP. LPA observations confirmed that R1 had access to care services and was not restricted from receiving medications, though he often declined them . Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Assistant Executive Director Lynn Torino, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. (Continued from LIC9099) It was alleged staff are not reporting incident(s) involving resident to their responsible party as necessary More specifically, RP reported that she learned from R1—not staff—that R1 had been involved in a physical altercation with another resident and was confined to his room afterward. R1 responsible person stated they was not notified by the facility until two days later and expressed concern that they consistently learn of incidents from R1 rather than staff. Interviews with staff revealed that the ED confirmed R1 was involved in an altercation and was assigned one-on-one supervision afterward. Staff acknowledged that verbal updates were provided to R1 responsible person but no written incident report was issued. During the department interviews R1 confirmed that he informed their responsible person of the incident themselves and stated they were confined to his room, although he had access to the outdoors via a sliding door. R1'S responsible person reiterated that they contacted by the facility after R1 had already told them. No outside sources contradicted R1 responsible persons account. A review of records confirmed that the incident was documented and follow-up actions were taken, but there was no evidence of timely notification to R1 responsible person. LPA observations confirmed that R1 had access to his room and outdoor areas but was not observed in common areas during the investigation period. Based on interviews and record review, the licensee did not notify the responsible person of a significant incident involving Resident #1 (R1), as required by regulation, a preponderance of evidence supports that staff did not consistently report incidents involving the resident to the responsible party as required. Therefore, the allegation is SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee staff. An exit interview was conducted, along with with Assistant Executive Director Lynn Torino, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.