LPA interviewed two residents (R3 and R4). Both R3 and R4 stated that prescribed medications were administered on time and that staff responded on time.

LPA interviewed R1’s Responsible Person (FM1). FM1 stated they did not have any concerns with the care provided to R1 at the facility, did not believe R1 was being neglected, and felt that the staff managed R1’s medications very well. FM1 stated that R1 was always in pain but never verbalized or requested pain medication. It was only when paramedics arrived that R1 expressed they were in pain; prior to that, R1 had not complained. FM1 further stated that the facility frequently communicated with them whenever R1 skipped a meal, refused medication, or when R1’s medications were running low. FM1 confirmed that they refused to have R1 transported to the hospital when paramedics arrived. However, after the paramedics left, after about an hour, when R1 began experiencing difficulty breathing again, FM1 agreed to have R1 sent to the hospital for evaluation.

On 06/04/2025, LPA reviewed R1’s and R2’s service plans. Based on LPA’s review, R1’s and R2’s service plans stated full assistance with the medication management.

Continued on LIC9099-C

On 06/04/2025, LPA reviewed R1’s Physician’s Report. Based on LPA’s review, the report had been electronically signed by R1’s physician on 11/21/2024 and stated that R1 was able to communicate symptoms clearly but was unable to determine the need for PRN medication.

Regarding the allegation ‘Staff did not assist resident with eating’, the Reporting Party (RP) alleged that the staff did not assist R2 with the dinner, and R2 had eaten very little.

On 05/12/2025, LPA toured the facility. During the tour, LPA observed eight (8) residents in the dining room on the first floor eating breakfast. One (1) staff member was observed feeding two (2) residents breakfast. One (1) resident was observed being fed breakfast by a staff member in the lobby area. LPA visited the medication room and observed one (1) Medtech in the room. LPA then took the elevator to the second floor, where two (2) staff members were observed assisting residents in their rooms.

On 05/12/2025 and 07/08/2025, LPA interviewed three (3) staff members (S2, S5, and S6), and three (3) residents (R3, R4, and R5).

S2 stated that there had been no service plan in place to provide feeding assistance to R2 when R2 first moved into the facility; however, staff still assisted R2 with feeding. S2 stated that the service plan was updated on April 27, 2025, to include feeding assistance for R2, but POA2 did not sign the updated plan. S2 further stated that on 04/27/2025, R2 had finished their dinner. The kitchen was locked after dinner, and the Med Techs had keys to access the kitchen. Snacks were provided between 6:30 and 7:00 PM and were available to residents both day and night. S5 stated that they had assisted R2 with feeding during breakfast and lunch, as well as with showering and changing clothes. S5 reported that R2 ate pureed vegetables and fruits, along with yogurt, served on a three-compartment plate. R2 ate very slowly, and some food would spill from their mouth, but R2 would finish their meals. S5 stated they were responsible for feeding two residents, including R2, during mealtimes in the dining room.

Continued on LIC9099-C

R3 stated that they had received three meals a day and snacks in between. R4 stated that they ate breakfast and dinner but did not eat lunch or snacks frequently. R5 stated that they remembered R2 as their roommate. R5 further stated that R2 appeared to have difficulty with swallowing, as food would often spill from R2’s mouth, and staff assisted R2 with eating mashed food. R5 stated that R2 experienced a heart attack and was sent to the hospital.

On 05/27/2025, LPA interviewed R2’s Power of Attorney (POA2). POA2 stated that they had observed signs of neglect in December 2024. POA2 reported that R2 required one-on-one assistance with feeding, but there were no staff available to assist R2 with feeding whenever they visited the facility. POA2 stated that feeding assistance was the primary reason for admitting R2 to the facility. POA2 further stated that they did not have any documentation confirming that R2 would receive one-on-one feeding assistance at the facility or outlining any specific feeding arrangements that had been agreed upon. However, POA2 mentioned they had informed the facility’s sales coordinator, who was no longer employed there, that R2 needed to be fed. POA2 also stated that R2’s Primary Care Physician (PCP) had expressed concerns about R2’s weight loss and had indicated PCP would speak to the facility regarding R2’s feeding needs.

On 07/08/2025, LPA interviewed R2’s Primary Care Physician (PCP). PCP stated that R2 had been diagnosed with ALS and that they had been seeing R2 every two weeks since R2 became their patient in January 2025. The PCP stated that R2 was on a pureed diet and required staff assistance with eating. The PCP further stated that during their visits to the facility, they observed on multiple occasions that R2 was receiving assistance from staff during meals, along with other residents. The PCP noted that staff at the RCFE had to take turns assisting residents with meals, as one-on-one service was not provided unless arranged through private pay. The PCP further stated that R2’s deterioration was consistent with the progression of ALS and not related to the food provided. R2 was receiving supplemental nutrition, such as Ensure. The PCP explained that muscle wasting was a symptom of ALS and that maintaining weight was difficult. The PCP emphasized that R2’s condition was due to a neurodegenerative disorder and not because the staff was not assisting R2 with the food.

Continued on LIC9099-C

On 06/04/2025, LPA reviewed R2’s service plans. Based on the LPA’s review, R2’s initial service plan had been created electronically on 11/14/2024 at 5:13 PM and was electronically signed by R2’s Responsible Person/Power of Attorney (POA2) on 12/02/2024 at 1:14 PM. The service plan stated that R2 required minimal assistance with meals and nutrition needs, with ‘Meal reminders or cueing to eat.’

R2’s updated second service plan was created electronically on 04/27/2025 at 4:48 PM, emailed to R2’s Responsible Person/Power of Attorney (POA2) on 04/27/2025 at 4:48 PM, which stated Full assistance with Meals and nutrition – Food services support during off meal times, encourage hydration, and special diet. Notes added stated “Per resident’s POA, resident needs assistance with feeding”. The second service plan was not electronically signed by R1’s Responsible Person/Power of Attorney (POA2). R2 went to the hospital on 04/27/2025 at 7:30 PM and never returned back to the facility.

On 06/04/2025, LPA reviewed R2’s Progress Notes. Based on LPA’s review, a Care Conference note had been entered electronically on 04/27/2025 at 04:56 PM. The note indicated that R2’s POA had requested assistance with feeding, and staff (S2) updated the service plan accordingly. S2 would contact ALW (Concise Care Group) regarding the increased level of care.

On 06/04/2025, LPA reviewed R2’s Assessment records. Based on the LPA’s review, the assessment had been completed electronically on 04/27/2025 at 4:46 PM. R2’s meals and nutrition needs were recorded as ‘Max-Full assistance with feeding and mealtime support'.

On 06/04/2025, LPA reviewed R2’s Activities of Daily Living (ADL) notes for April 2025. Based on LPA’s review, the records indicated that R2 had been consuming between 80% to 100% of breakfast, lunch, and dinner.

On 06/04/2025, LPA reviewed R2’s weight log. Based on LPA’s review, R2’s recorded weights were as follows: 97.5 lbs. on 01/07/2025, 96.6 lbs. on 02/02/2025, 95.5 lbs. on 03/19/2025, and 94.6 lbs. on 04/17/2025.

Continued on LIC9099-C

On 06/04/2025, LPA reviewed R2’s Medication Administration Record (MAR). Based on LPA’s review, Ensure had been given to R2 daily from April 15 to April 27, 2025. Hydrocodone 5-325 mg tablets had been administered every day at 8:00 AM and 8:00 PM, and Voltaren (Topical) 1% Gel had been applied three times daily. There were no documented refusals or missed doses. Additionally, PRN medication Meclizine 25 mg oral tablet had been administered for dizziness on 04/22/2025.

Based on observations, interviews conducted, and records reviewed, the information LPA received regarding the allegations are conflicting. The department has determined that the allegation(s) may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegation(s) are UNSUBSTANTIATED.

No deficiencies were cited under the California Code of Regulations, Title 22.

An exit interview was conducted with the Resident Care Coordinator. A copy of this report was discussed and provided to the Resident Care Coordinator, Bernadette Kang, whose signature on this form confirms receipt of this report.