Complaint·July 30, 2025

(Continue from LIC9099) Through these investigative methods, the Department assessed the facility’s compliance with applicable laws and regulations, as well as the quality of care provided to R1 during the period in question. According to the complaint, on April 3, 2025, at approximately 7:30 a.m., during the administration of morning medications, staff observed a change in R1’s condition and initiated a 911 call. R1 was subsequently transported to the hospital by emergency personnel. The incident report submitted to CCL indicated that R1 exhibited signs consistent with a stroke, including facial drooping on the right side, confusion, and general weakness. Resident Background A review of R1’s medical records showed that upon admission to the facility in March 2024, R1 required maximum assistance with all activities of daily living. R1 had multiple chronic medical conditions, including malignant neoplasm of the prostate and bone, a history of urinary tract infections (UTIs), repeated falls, malnutrition, and anemia. The functional needs service plan dated April 5, 2024, stated that R1 was at heightened risk for sudden changes in condition and required close observation and monitoring. The service care plan for R1 also required full assistance with incontinence care, grooming, bathing, dressing, ambulation, transfers, and escorting. Additionally, R1’s Foley catheter was to be managed by an outside home health agency. Findings The Department reviewed hospital records and conducted multiple interviews with external sources, which confirmed that R1’s change in condition on April 3, 2025, was due to a severe bacterial infection (sepsis) originating from a UTI. External sources reported that R1 was admitted in a severely deteriorated state and required care in the intensive care unit (ICU) for four days, followed by an additional ten days of hospitalization. R1 also tested positive for COVID-19, was dehydrated, and had multiple pressure ulcers. Interviewees reported that R1 arrived at the hospital saturated in urine from the shoulders down. Additionally, R1 experienced a significant and undocumented weight loss—from 64 kg on March 5, 2025, to 51.7 kg on April 3, 2025. Staff confirmed that this weight loss and overall change in condition were neither observed nor reported to R1’s medical team, as required and missed an opportunity for timely medical intervention. (Continue at LIC9099C) (Continue from LIC9099C) Further, the investigation found that there were no records of home health agency visits after March 13, 2025. Staff stated they were unaware of why the visits had ceased, and the investigation could not determine whether the agency formally discontinued services. Staff interviews consistently revealed concerns about insufficient direct care staffing. Staff interviews consistently indicated that staffing shortages were an ongoing issue during the time of the incident. Management acknowledged the use of an external staffing agency to fill gaps and to compensate for direct care staff shortages. During a visit on April 10, 2025, it was observed that the Executive Director was acting as a medication technician due to staff callouts. Interviews with staff and residents further confirmed that non-direct care staff were frequently pulled to cover care shifts, and medication administration was often delayed due to staffing shortages. While no adverse outcomes from late medication administration were reported, it was confirmed that incontinence care was not provided to R1 before the arrival of emergency personnel on April 3, 2025, due to a short-staffed night shift. A review of the facility’s staffing schedules for the relevant period could not verify whether all scheduled shifts were adequately staffed, as coverage for unscheduled absences was not consistently documented, and not all the staff involved were available to comment. As of May 2025, the facility is under new management. The current administration has prioritized increasing staffing levels to ensure sufficient care. Follow-up interviews with staff, residents, and external sources confirmed that current staffing is adequate to meet residents’ needs. Conclusion Based on the evidence obtained through interviews, observations, and a review of records, the Department determined that there is sufficient evidence to substantiate the allegations. Staff neglect resulted in R1’s hospitalization, medical attention to meet R1 needs was not appropriately addressed, and incontinence care was not adequately provided to meet R1’s needs. (Continue on LIC9099C) (Continue from LIC9099C) The Department finds the allegations to be substantiated, meeting the preponderance of evidence standard. Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations, and are detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Executive Director EJ Lewis. In accordance with Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Executive Director Lewis, who was provided with a copy of this report, the LIC 9099-D Deficiency Report, the LIC 811 Confidential Names List, and the LIC 9058 (03/22) Licensee Appeal Rights.