There is an allegation of "Staff mismanaged resident's medications." - Complaint alleged that facility did not have R1’s nebulizer or albuterol. Per complaint, R1’s albuterol was unavailable and therefore facility staff were “borrowing” the medication from another resident. Complaint was unable to provide additional information such as which resident the facility staff was borrowing albuterol from or when the albuterol was borrowed. Complainant stated that R1 received physician orders for the nebulizer equipment and albuterol medication on 01/07/2026 and 01/20/2026. Complaint stated that R1 did not have albuterol or their nebulizer on 02/04/2026, but did have their nebulizer available on 02/11/2026. Complainant further alleged the following: R1 had a rectal suppository medication for hemorrhoids and it was not available, facility was not following R1’s torsemide medication order stating that the facility was to check R1’s blood pressure before administering the medication, and that facility removed R1’s half bed rails even though R1 had a physician's order for it. Per Complainant, R1 received an order for half bed rails in May 2025 but the bed rails were removed in February 2026 when R1 moved to the facility’s Extended Care area. Complainant stated that R1 received a new order for half bed rails on 01/07/2026.

R1’s progress notes stated that R1 was monitored for changes in their breathing and was offered treatments if observed. Per notes, R1 was administered or offered their “as needed” breathing treatments on the following days:

• 01/09/2026, R1 received their nebulizer treatment after being observed to have SOB (Shortness of Breath) in the afternoon.
• 01/12/2026, R1 was observed to have SOB but refused both their nasal spray and nebulizer treatment.
• 01/26/2026, R1 received inhaler due to experiencing SOB during physical therapy visit.
• 02/12/2026, R1 received nebulizer treatment after being observed to have worsened respiratory symptoms and increased weakness.

• Filled on 10/20/2025, expiration date 01/2027, with 3 refills
• Filled on 11/25/2025, expiration date 04/2027, with 2 refills
• Filled on 02/18/2026, expiration date 03/31/2027, with 0 refills

3 of 3 staff interviews conducted stated that they haven’t administered albuterol from another resident to R1.

Torsemide: Complainant informed the Department that documentation of R1’s blood pressure (BP) for the Toresmide parameters was located. Review of documents showed that R1 had blood pressure and vitals taken in February and March 2026. Review of R1’s after visit summary and medication list dated 02/25/2026 stated that R1 received an order for Torsemide which stated, “Torsemide 20mg tab: Take 1 tablet by mouth daily.” There was no indication of any parameters stated in the medication order. Review of R1’s face sheet information and medication list updated 03/11/2026 stated, “Torsemide, 20MG Tablet – give 20MG tablet by mouth, one time per day, every day. Take one tablet by mouth every day." There was no indication of any parameters listed in the medication order.

Continued on LIC9099C

3 of 3 staff interviews conducted stated that vitals such as blood pressure, are to be taken once a month, unless otherwise instructed.

Bisacodyl Rectal Suppository: Review of R1’s physician orders dated 04/09/2024 and 02/15/2026 showed that R1 had an PRN or “as needed” medication for Bisacodyl Rectal Suppository 10MG (Bisacodyl), which stated, “Insert 1 suppository rectally as needed for constipation.”

Review of R1’s after visit summary and medication list dated 02/25/2026 indicated that there was no longer an order listed for a PRN Bisacodyl Rectal Suppository. Review of R1’s electronic medication authorization record (EMAR) showed that the suppository order was discontinued in February 2026 and therefore was not needed. EMAR further stated that R1 did not require a suppository in January 2026.

Bed Rails: Review of facility’s policy dated 03/2025 stated that “…residents needing bed mobility devices are provided with safer alternatives to bed side rails…Bed rails of any type, e.g. full, half, quarter, etc. shall NOT be used in any LCS (Life Care Services) Community.” Per facility procedure, any licensed physical/occupational therapist shall be made aware of the “No Bed Rails” policy at the time of a resident’s evaluation to ensure that bed rails not recommended.

Review of R1’s LIC602/medical assessment dated 04/25/2025 stated that for transfers, R1 was to utilize a Sit-to-Stand Machine and use a front wheeled walker. Review of R1’s discharge paperwork and after visit summary dated 01/03/2026 did not indicate any new orders related to bed rails. Review of R1’s progress notes stated that on 01/06/2026, facility held a care conference to discuss multiple areas of care including physical therapy and occupational therapy. Notes stated that R1 continued to use the sit-to-stand machine with no changes.

Review of R1’s discharge paperwork dated 02/15/2026 under “Inpatient Physical Therapy Evaluation” stated that R1 previously used a hoyer lift. It further stated that R1’s goals were to assess transfers with a hoyer lift and wheelchair management.

Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated.

There is an allegation of "Facility did not ensure maintenance of resident’s personal care equipment." Complaint alleged that facility lost R1's APP overlay and that only the motor was in place. The Department was provided with the following timeline: R1's APP overlay was provided by Kaiser and was first observed to be gone on 02/04/2026. R1 went to the emergency room on 02/03/2026 and their APP overlay was observed to be gone on 02/11/2026. On 02/18/2026, R1's physical therapy and occupational therapy located and installed R1's APP overlay. R1 then went to the hospital from 02/19-02/25/2026. On 02/27/2026 it was observed that R1's APP overlay was not on the bed.

Per Complainant, an order was placed with Kaiser for a replacement, and R1's responsible party stated the overlay had

Continued on LIC9099C

Interview conducted with Staff Member 3 (S3) stated that durable medical equipment is coordinated through the resident's home health agency while their medical provider is responsible for obtaining the order. Per interview, the facility's process for replacing missing equipment is to reach out to the party or provider who supplied it to arrange for a replacement.

During visit on 03/12/2026, a light blue bubble overlay was observed on R1's bed.

Based on interviews conducted and observations made, this allegation is Unsubstantiated.

There is an allegation of "Staff do not have proper training." Complaint alleged that facility staff didn't seem to know how to manage R1's foley catheter. Per Complainant, it had been observed that R1's catheter tubing was not attached or secured to their leg, and that the catheter urine bag was noted to be full on two separate occasions.

Review of R1’s discharge paperwork dated 02/15/2026 stated that R1 had a referral to Urology following placement of their foley catheter. Review of R1's LIC602/medical assessment dated 02/15/2026, stated that R1 had a foley catheter in place.

Review of R1's progress notes stated that R1 returned to the facility on 02/25/2026 with an in-dwelling catheter in place. This pogress note stated that R1's home health agency would manage R1's catheter.

Interview conducted with HWD stated that there hasn't been any training for caregivers, medtechs, or CNAs (Certified Nursing Assistants) on catheter care as the assigned home health agency would be responsible for managing it. HWD later stated that they believe catheter care training had been done before through an outside agency like hospice, but was unable to locate proof of documentation.

Staff interviews were conducted. 3 of 4 staff interviews conducted stated that they have received training on catheters. 1 of 4 interviews stated they had not received training on catheter care. 1 of 4 interviews stated that they did not receive their catheter training from the facility and received catheter training from another source. 2 of 4 interviews stated they received catheter training but were unable to state if it had been provided by the facility or from another source. 4 of 4 staff interviews all stated that if a resident has a catheter, they are to empty the bag. 2 of 4 staff interviews also stated they are to ensure the bag is positioned correctly or attached to the resident's leg.

Review of staff training on Relias indicated that staff received training on how to assist with resident ADLs. Interview with Business Office Manager and HWD were unable to confirm if the ADL training module had a section covering catheter care.

Continued on LIC9099C

A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.