Allegation: Neglect/lack of care and supervision – facility retained resident with prohibited health condition:

The complaint alleges that while Resident #1 (R1) was receiving care at the facility, R1 sustained a wound and the facility retained the resident with the prohibited health condition. Interview revealed that facility staff and R1’s family were aware of the resident sustaining a pressure injury in August or September 2025. When staff initially discovered R1’s wound, it was described as appearing red and with intact skin. The wound was noted in R1’s care notes on 09/15/2025. On 09/16/2025, home health began treating R1’s pressure injury. Home health classified the buttock wound as stage 3. Notes document the progression of R1’s wound and ongoing treatment provided through the home health company. Documentation further indicates that the facility was notified of R1’s condition through external agency forms, however the facility did not request nor obtain an exception to retain R1 with the prohibited health condition. Additionally, staff did not initiate transfer to an acute care hospital for appropriate medical intervention. R1 was not admitted to the hospital until 10/28/2025 for unrelated concerns, not due to the wound. Interview with clinical director revealed they were unaware that the wound constituted a prohibited health condition, therefore, transfer to an appropriate level of care was delayed. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation is deemed SUBSTANTIATED at this time.

Allegation: Staff did not properly administer medications to a resident in care:

The complaint alleges that staff are popping medications for Resident #2 (R2) out of the bubble pack and then placing them back in the bubble pack and marking the medication as administered. Medication review and interview with facility staff revealed that R2’s Percocet is prescribed on an as needed basis and R1 can take ½ to 1 tablet as needed (PRN). Interview revealed that due to the way the prescription is written, facility staff are taking the pill out of the bubble pack and administering either 1/2 tablet or the whole tablet, depending on what R2 requests. If a 1/2 pill is administered, the medication technician will return the other

Report Continued on LIC 9099-C (p.3)

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Facility Designee was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.

Allegation: “Neglect/lack of care and supervision – Resident developed pressure injury due to facility neglect:”

The complaint alleges that R1 developed a pressure injury due to the facility’s lack of care and supervision. Interviews revealed that when staff observe a resident is experiencing skin integrity concerns, staff will take proactive measures to mitigate any potential breakdown. When a resident’s skin appears red or irritated, staff will apply cream as a protective barrier. Staff report to the wellness coordinator or wellness director, who will communicate with the resident’s physician and family. Staff also indicated that they regularly reposition residents with limited mobility to limit the potential for pressure-related skin breakdown. In the case of R1, who did have limited mobility, staff were repositioning when they provided incontinence care. During the day, R1 was able to communicate their needs and would inform staff when they needed incontinence care. At night, staff stated they changed R1 one (1) to two (2) times during the overnight shift and would attempt to reposition R1 at those times. Staff also stated that R1 did not wish to be repositioned when they were in a comfortable position. Interview with wound specialist who treated R1 indicated the wound on R1’s buttocks “this was not a pressure sore.” Instead, the medical professional stated it was probably a result of “soiling, fecal soiling with wiping…it ate through the skin…” Another medical professional who treated R1 indicated they observed no signs of neglect and factors that may have contributed to the wounds were “lack of mobility and prevention from moving around.” Interviews revealed the facility staff was in communication with R1’s family related to R1’s skin breakdown and that the family was also in communication with R1’s medical team. 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 “resident developed pressure injury due to facility neglect” is deemed Unsubstantiated at this time.

Allegations: “Facility did not provide timely medical transport” and "Staff did not ensure that resident attended medical appointments:"

The complaint alleges that Resident #3 (R3) required blood transfusions and due to facility neglect, R3 missed appointments, placing R3 at risk of serious bodily harm. Records reviewed for R3 revealed that due

Allegation: "Staff are falsifying medication logs:"

The complaint alleges that medications are marked as administered on the MAR for R2, even when pills are observed taped back into the bubble pack. As described in page two (2) and three (3) of the complaint report, R2's Percocet is ordered to be administered 1/2 to 1 tablet as needed (PRN) for pain. R2 is capable of communicating the requested dosage to the staff. If R2 only requests a 1/2 tablet, the medication

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

Allegation: "Staff are smoking in the facility:"

LPA interviewed staff and residents related to the facility's smoking policies and observations. Both staff and residents interviewed indicated the facility has a smoking area on the outside patio on the second floor of the facility. There is an additional smoking area designated on the first floor exterior as well. Residents indicated that at times they can smell smoke coming inside the building from the smoking area, as doors and windows are left open for fresh air. No staff nor residents have ever seen anyone smoking inside the facility. Additionally, the complaint mentions marijuana is smoked inside the facility and no resident nor staff have observed any person smoking marijuana on the premises at all. 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 are not showering residents in care:"

The complaint alleges that residents are not showered regularly. Interviews revealed that most residents that require assistance with showering are on a two (2) showers a week schedule. The shower schedule has been modified a number of times, based on resident requests. Some prefer morning showers, some prefer to shower in the evening. Some residents prefer a particular staff person to assist with their showers, which the facility tries their best to accommodate, however, can't always accommodate everyone. The facility does document when a resident refuses their shower and has a process for informing family and physician when needed. Residents interviewed indicated that yes, there are some residents who refuse shower assistance, but the facility does their best to encourage adequate hygiene. Although the allegation may have happened

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

Allegation: "Staff left a resident in soiled bedding for an extended period of time:"

The complaint alleges that Resident #4 (R4) was soiled and left in their bed for an extended period of time. Interviews with staff revealed that R4 is bedbound and unable to transfer on their own. R4 does require assistance with incontinence care. Staff interviewed stated that incontinence care is provided at least two (2) times per shift, or more frequently as needed. Additionally, during change of shift, staff conduct rounds where both incoming and outgoing staff check on the residents and communicate to ensure continuity of care for the residents. Staff interviewed have never observed a resident left soiled for a lengthy period of time. Residents interviewed felt their care needs related to incontinence are met. 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 did not ensure that hazardous items are inaccessible to residents in care" and "Staff did not ensure that medications are inaccessible to residents in care:"

The complaint alleges that frequently items are left unlocked in the memory care unit, leaving a multitude of medications, creams, and other personal care items accessible to residents in care. LPA observed the facility's memory care unit during multiple visits throughout the course of the investigation and never once observed cabinets or storage areas to be unlocked. Interview with facility staff revealed there are locked storage areas in resident rooms and common areas for personal care items to be stored. Facility staff interviewed have not observed these items left out and/or accessible to residents in care. All medications for both the memory care unit and the assisted living unit are stored in a locked medication room, located in the Assisted Living. 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 did not notify resident's responsible party of an injury:"

The complaint alleges that Resident #5 (R5) sustained a bruise and R5's responsible party was not notified of the injury. LPA interviewed facility staff, who indicated if a resident is found with a bruise, progress notes

Report Continued on LIC 9099-C (p.10)

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