Allegation: “Staff violated resident’s personal rights:”

The complaint alleges that R1 was never taken outside the facility nor was R1 transferred out of their bed during the time R1 lived at the facility. Additionally, reporting party indicated the television in R1’s room was broken and R1 was left in their room by themselves with nothing to watch. During all 3 (three) visits at this facility, LPAs observed that all non-ambulatory residents were in their own rooms. LPAs observed no planned activities occurring. Residents interviewed stated they remain in their beds during the day, as staff do not give them the option to get up. One resident reported that they are able to use the restroom with transfer/escort assistance and they prefer to use the restroom for their toileting needs. However, this resident reported that care staff have told the resident to use their diaper, and the staff will provide incontinence care for this resident. This resident and their family member both stated that the resident has only gotten out of bed 2 (two) times in the 2 (two) months they have lived at the facility because it is too difficult for the staff to lift the resident. Resident stated they would prefer to get out of bed daily and exercise their legs. Although LPA was unable to interview R1 related to this allegation, on 06/19/2025, LPA confirmed the television in the room R1 lived in does work but is difficult to operate. The resident required assistance from the LPA to operate the television, as the resident was unable to read and follow the written instructions for the television. R1’s preplacement appraisal information indicates R1 likes to watch tv and sing. As either the television was not working or R1 was unable to operate the television independently, R1 was unable to engage in their choice activity. Based on interview and record review, the preponderance of evidence standard has been met, therefore, the allegation “staff violated resident’s personal rights” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC9099-D). Staff was informed that failure to correct to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of today’s report and appeal rights were provided.

Allegation: “Staff did not prevent resident from sustaining pressure injuries:”

The complaint alleges that R1 sustained pressure injuries on their back due to staff not repositioning R1 while in care. Review of R1’s hospice plan of care indicates R1 was admitted to hospice care while residing at another location on 07/09/2024. R1 was then diagnosed with a fungal infection on 07/15/2024, which was noted to be unresolved as of 09/11/2024.” It should be noted that R1 moved into this facility on 08/22/2024, but this fungal infection was not noted on any of R1’s intake paperwork for this facility, including the physician’s report. Physician’s report dated 08/19/2024, the form is marked yes to history of skin condition or breakdown, with a comment reading “sensitive skin, but there was no indication of any pressure injuries at that time. Although interview revealed that R1 was under hospice care the entire time R1 lived at the facility, no hospice paperwork reviewed indicated R1 had any pressure injuries at any time. LPA was unable to obtain any documentation of any pressure injuries, either from the facility or from the reporting party. Additionally, interviews with facility staff and Administrators revealed R1 did not have any pressure injuries they were aware of at any time while R1 was residing at the facility. Staff interviewed indicated that bedridden residents are repositioned every 2 hours and residents interviewed corroborated that staff assist in repositioning if the resident is unable to do so. R1’s physician’s report indicates R1 was non-ambulatory, but not bedridden. Per the definition stated on the physician’s report “a person who is unable to independently transfer to and from bed, but who does not need assistance to turn or reposition in bed, shall be considered non-ambulatory.” As R1 was non-ambulatory, R1 would have been able to reposition themselves. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Allegation: “Staff caused injury to resident:”

The complaint alleges that while staff were changing R1, staff bumped R1’s head on the bedrails, causing

Report Continued on LIC 9099-C (p.6)

Allegation: “Conduct inimical:”

It was alleged that new Administrator lied to court investigators related to R1’s Power of Attorney (POA.) LPA requested legal documents related to a POA, but Administrator reported none were provided. LPA reviewed R1’s admission agreement, in which R1’s name is printed in the resident’s signature line and in the same handwriting, R1’s family member’s name is printed in the signature line for resident’s responsible person. R1 signed their own physician’s report and there are various unidentifiable signatures on R1’s pre-appraisal, needs and service plan, and resident appraisal. R1’s physician’s report does indicate R1 cannot manage their own cash resources and under comments it indicates “POA.” However, LPA was unable to find any document that indicates who is designated in the resident’s POA or if any such document exists. Prior to R1 being admitted to the facility, R1 had been hospitalized. LPA reviewed hospital documentation for any indication whether R1 had a legal power of attorney or other legal document indicating a person responsible for R1’s medical and/or financial affairs. On 06/05/2024, hospital social worker had indicated that R1 had been “deemed unable to make decisions for [R1’s self] and no family has stepped up to assist with this process.” While in the hospital, a bioethics committee convened, and it was decided to discharge R1 to a board and care. It appears based on hospital record review that R1 did not have a POA at that time. Interview with staff revealed that while R1 was residing at the facility, R1’s family member asserted that they were R1’s decision maker and attempted to block another family member from visiting R1, but no legal documentation was provided to the facility. It is unclear whether there was any legal documentation related to R1, therefore

Report Continued on LIC 9099-C (p.7)

Allegation: “Staff are not providing adequate food service to a resident:”

LPA interviewed residents and staff, as well as observed food supply during all 3 (three) visits related to this complaint. LPA observed an adequate amount and variety of foods during all 3 (three) visits. Residents interviewed stated they are served 3 (three) meals a day as well as snacks upon request. Examples of food residents stated they are served include: porridge, cereal, or eggs for breakfast, sandwiches and soups for lunch, and chicken, beef or fish for dinner. Residents stated they receive more than enough food. Staff also indicated that 3 (three) meals are served a day and that lunch typically includes a sandwich of the resident’s choosing as well as soup. Staff interviews revealed that as far as R1, sometimes R1 would eat on their own and sometimes R1 required assistance with feeding. Staff would serve R1 the meal prepared and after, R1 would ask for more food. Staff stated that R1 asked for peanut butter and jelly sandwiches every day and that R1 would eat the food served as well as the sandwiches for meals. Reported party stated that R1 wouldn’t eat their meals right away and by the time R1 would, the food was stale, however, staff denied this ever occurring. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Allegation: “Call button not being responded to in a timely manner:”

During the initial and subsequent visits, LPA heard call buttons being pressed and staff responding timely to assist residents. LPA observed wait times around 1 minute during the visits. Residents interviewed stated the staff are responsive to their needs and come to their rooms quickly when residents use their call buttons. One resident commented that the call buttons sound the same as the doorbell, so sometimes staff will respond to the resident rooms to assist when a visitor is at the front door. Staff and Administrator stated that R1 would use their call button often to request additional food or other assistance and that staff would always respond promptly. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to

Report Continued on LIC 9099-C (p.8)

Allegation: “Staff did not ensure resident’s call button was accessible:”

It was alleged that R1’s call button was left too far away for R1 to reach it, therefore R1 was unable to call for assistance when needed. During all visits to the facility, in all occupied rooms, LPA observed the residents’ call buttons on their beds or within the residents’ reach. 1 (one) resident had a call button on their bedside table and out of reach, however, both staff and family member stated that the resident is incapable of pressing the button. LPA attempted to interview this resident, but LPA did not receive a response. All other residents interviewed stated their call buttons are always accessible and that there have been no concerns with being able to reach staff when needed. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Allegation: “Facility is not adhering to resident’s Admission Agreement:”

The complaint alleges that when R1 moved into the facility, R1 was in a shared room but that shortly after moving in, R1 was moved into a private room and additional fees were charged. Interview with Administrator revealed that when R1 moved into the facility, the private room was occupied and therefore R1 was moved into a shared room. However, when the private room became available, R1 was moved into this room, as this room has a fire clearance for bedridden residents. Administrator stated that R1 was not charged an additional fee for the private room. It is unclear why R1 was moved to the private room with bedridden fire clearance, as R1 was non-ambulatory, not bedridden according to their physician’s report. LPA reviewed R1’s Admission Agreement, which was signed by R1’s responsible person on 08/22/2024. Admission Agreement states “the monthly rate for basic services is $1300.” Under optional services, R1’s Admission Agreement states “Private room $______ additional fee.” R1’s responsible person initialed this section; however, no fee was written in nor is R1’s room assignment or whether the fee indicated is for a shared or private room. According to the reporting party, R1 paid $1300 monthly for 2 (two) months while living at the facility, which appears to be R1’s contracted rate. Although R1’s room was changed and no written notice was provided, it is unclear whether this was communicated up front when R1 moved in, if the move was the facility’s decision or if R1

Report Continued on LIC 9099-C (p. 9)

No citations issued related to the above allegations. Exit interview conducted. A copy of today’s report was provided.