complaint·March 3, 2026

(Continued from LIC9099) Department review of R1’s Physician’s Report shows diagnoses including cerebrovascular accident (CVA) with right sided hemiplegia, mild cognitive impairment (MCI), and dementia. R1 was admitted to the facility on March 29, 2025, following transfer from a skilled nursing facility, and required full assistance with Activities of Daily Living (ADLs). Departments review of R1’s Medication Administration Record (MAR) shows clonidine patches were documented as applied per physician orders on 3/31/2025, 4/7/2025, and 4/14/2025. Further record review reveal that on April 19, 2025, staff observed a change of condition during the dinner hour. At 8:46 PM, staff contacted emergency services, and R1 was transported to the hospital. Department Hospital records review dated April 19, 2025, confirm that two Clonidine patches were present and removed during R1’s admission: one patch dated 3/28/2025 located on right side of the neck and one undated patch located on the right shoulder. Department interviews with staff revealed they were unable to provide documentation explaining how the duplicate patches occurred. Under Title 22, the licensee is responsible for ensuring medications are administered as prescribed and for maintaining records and oversight to prevent medication errors. The presence of two Clonidine patches is inconsistent with physician orders and MAR documentation and demonstrates a failure to properly assist with medication administration and monitoring. The Department has investigated the above mentioned allegation, and based on interviews and records review, the preponderance of evidence has been met. Therefore, this allegation is deemed substantiated . The following deficiency for failure to ensure proper medication assistance and oversight is cited per California Code of Regulations, Title 22, and is noted on the attached LIC 9099D page. An exit interview was conducted with Executive Director Angela [Last Name], whose signature below confirms receipt of this report and the Licensee Appeal Rights (LIC 9058 03/22). (Continued from LIC9099) Department record review of R1's physician report revealed R1 is diagnosed with cerebrovascular accident (CVA) with right-sided hemiplegia, along with mild cognitive impairment (MCI) and dementia. It further revealed R1 was non-ambulatory and needed full assistance with Activities of Daily living (ADL's) R1 move in date to the facility was March 29, 2025 and was transported to the facility from a skilled nursing facility. Department records review revealed hospice services visits began July 24, 2025, with a primary diagnosis of Neurocognitive disorder along with Lewy bodies and related issues of Muscle weakness, Cerebral atherosclerosis and Abnormal weight loss. Department review of hospice documentation also included maximum assistance and up in wheelchair as and tolerated for R1. Records review further reveal hospice services for wound care began on August 8, 2025. Hospice documentation shows wound care was provided per physician orders, including daily dressing changes, multiple weekly treatments, and nutritional support. Department review of facility records, outside source records, as well as outside source interviews and staff interviews reveal facility staff implemented non-skilled interventions within their scope and per physician orders, such as R1 sitting for periods of time in wheelchair, repositioning and offloading, and documented communication with hospice and the R1's responsible party. Department records review further reveal wound care products, nutritional supplements and medications were administered as ordered. However departments review of the Medication Administration Record (MAR) and facility care notes reveal multiple medication and nutritional supplement drink refusals by R1. Department review of facility records, outside source records, as well as outside source interviews and staff interviews reveal R1's equipment orders per Hospice physician orders, reveal that that pressure-relief equipment, including an alternating pressure pad and a low air loss mattress, was delivered and installed prior to hospitalization in October 2025. This agency has investigated the complaint alleging that the licensee failed to provide timely wound care and failed to ensure appropriate equipment was in place for the resident. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED . An exit interview was conducted, and a copy of this report and Licensee Rights (LIC 9058 03/22) was provided. Executive Director Angela Scott- Kapilof signature on this form confirms receipt of these rights.