Allegation: Staff are not properly caring for resident’s open wound

It is being alleged that upon admittance to Martin Luther King Jr. Community Hospital on 10/15/25, C1 had a wound and a blister on his left leg. On 4/20/26, the department reviewed records and found the following: Date admitted to the facility, per Admissions Agreement, 12/23/24. Diagnosis on admissions per Physician’s Report dated 11/22/24, diabetes, chronic kidney disease, and activities of daily living (ADL’s). Per review of Preplacement Appraisal dated, 12/23/24, overall health condition included diabetic neuropathy, non-ambulatory due to blindness, could dress on his own, needed assistance with bathing, medication, and cash. Per interview with S1 on 10/20/25, staff only does body checks upon admission and it was not known that C1 had a wound on his leg. S1 stated that C1 does not inform staff when he takes a shower. Per interview with S1, C1 only request towels when he’s done with his showers. Per review of Resident’s Shower Slips dated, 10/3/25 and 10/10/25, C1 requested towels after his showers. Per review of Needs and Services Plan dated, 12/23/24, C1 was able to move on his own and do ADLs with minimal assistance and encouraged to take showers. Per Report of Behavior Observed by Staff, dated 8/26/25, stated C1 went into facility’s office to inform staff that he went to the doctors and he submitted paperwork to staff which stated C1 was diagnosed with cellulitis of the leg, with no follow up appointments nor medication given. Per incident report dated 10/15/25, C1’s caseworker visited this facility to notify staff that C1 was admitted to the hospital following an evaluation. Per C1’s request, the caseworker stated the admission was for high blood pressure to conceal the actual reason from staff. On 10/15/25 following a medical evaluation, MLK Hospital diagnosed C1 with a diabetic skin ulcer. Per review of Report of Behavior Observed by Staff on 10/18/25, a facility resident mentioned to staff that he would see C1 scratch at the back of his leg with his shoe. Per interview with S1 on 4/20/26, C1 transferred to another facility on 11/4/25. On 4/20/26 and 4/23/26, the department attempted to interview C1, but he refused LPA Shirleys telephone call.

LPA interviewed staff 1 – staff 5 (S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed Client 2 – Client 6 (C2 – C6). Of those who interviewed 5 out of 5 denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not properly caring for resident’s open wound,” therefore, the allegation is unsubstantiated.

Con'd on 9099-C

It is being alleged that C1 stated that other residents are being left unattended and are not being assisted with their incontinence needs in a timely manner. During interviews on 4/20/26, LPA Shirley interviewed S1-S5 and all staff members stated that there is an incontinence log to track the times residents are assisted with incontinence needs. On 4/20/26, LPA Shirley reviewed entries for 5 resident’s on the incontinence log and observed that these residents are being checked every 2 to 3 hours to determine if resident requires assistance with their incontinence needs.

LPA interviewed staff 1 – staff 5(S-1 – S-5). Of those interviewed 4 out of 5 denied the allegation. One staff member did not know. LPA interviewed Client 2 – Client 6 (C2 – C6). Of those who interviewed 3 out of 5 denied the allegation. One did not know and 1 go on there own.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure residents' incontinence needs are being met,” therefore, the allegation is unsubstantiated

Allegation: Staff do not prevent residents from using illegal drugs

It is being reported that residents are using illegal drugs inside of the facility. On 4/20/26, LPA Felisa Shirley reviewed incident reports from April 2025 to present which yielded no evidence of drug related incidents. On 4/20/26 LPA Shirley interviewed S1 – S5 and noted that they never witnessed drug use at this facility. Of those who interviewed 5 out of 5 denied the allegation. LPA interviewed C2 - C6. Of those who interviewed 5 out of 5 denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not prevent residents from using illegal drugs,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Med Tech, Jackie Alfaro.

con'd on 9099-C

It is being alleged that C1 is being given more medication than he is supposed to receive. On 4/20/26, LPA Shirley reviewed C1’s Medication Administration Records, (MARs), for 10/1/25 to 10/31/25. Upon reviewing the resident’s MARs, LPA Shirley observed that all medications were administered as prescribed, with the exception of the Erythromycin. The official instructions require twice-daily application for 10 days. However, the original documentation was modified, an initial 15-day schedule was whited out over the final 5 days, leaving those dates blank. Per interview with S1 on 4/20/26, she stated that she could not recall why those dates were modified.

LPA interviewed staff 1 – staff 5(S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed Client 2 – Client 6 (C2 – C6). Of those who interviewed 5 out of 5 denied the allegation. LPA attempted to interview C1 but they refused.

According to the information gathered there is sufficient evidence to support the allegation “Staff are mismanaging resident’s medication.” Based on interview and record review the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8.