The complaint alleges that the facility did not obtain timely medical attention for Resident #1 (R1) when R1 was experiencing a high fever during the overnight (NOC) shift. At the time of the complaint, no staff working during the overnight shift were trained on medication administration, which was confirmed during interview with the ED and record review. Interviews with staff revealed differing information on the facility's medical plan during the NOC shift. Some staff interviewed stated that they have a list of staff and management to call when there is an emergency or a resident has an unmet medical need during the NOC shift. However, other staff indicated they are to call 9-1-1. Staff interviews revealed R1 did experience a fever one night and NOC staff were informed by the previous shift's medication technician that a hospice nurse would be arriving to tend to R1's needs. When R1's hospice care provider did not arrive, NOC staff were unaware of how to respond to R1's unmet medical need. Staff present at the facility were unable to administer prescribed as needed (PRN) fever reducing medication to R1, as no one present in the facility was trained on medication administration. Although staff interviewed indicated there are no residents that have regularly prescribed medications scheduled for administration during the NOC shift, PRN medications can be needed at any time, including the NOC shift. On 11/04/2025, a Corrective Action Plan was issued to the facility by Tri-Counties Regional Center related to this allegation. Based on the information gathered during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Designees were 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.

On the allegation "Staff do not position resident in bed properly to avoid injury:"

The complaint alleges that Resident #2 (R2) experienced upper body weakness and has injured their face on the bedrails due to staff not properly positioning R2 in bed. LPA and QA were unable to locate any incident reports relating to an injury to R2's face. Staff interviewed could not recall seeing R2 with any injuries to their face in the past several months. Staff interviews revealed that all residents who cannot reposition themselves are repositioned by staff regularly and at minimum every two (2) hours. 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.

On the allegation "Staff do not change residents timely:"

The complaint alleges that residents are sitting in soiled diapers for hours. Staff interviewed indicated that incontinence care is provided to residents every two (2) hours or more often as needed. During all complaint visits conducted at the facility, LPA and QA did not observe evidence of any unmet incontinence needs. All residents appeared clean and dry; no incontinence odors were observed. No additional information was provided relating to specific residents affected or a specific time frame during which the allegation was referring to. Management indicated training is provided to all staff relating to incontinence care and hygiene needs and to their knowledge, staff abide by all protocols relating to incontinence care. 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.

Report Continued on LIC 9099-C

It was alleged that all laundry is mixed, which is not sanitary. LPA reviewed the facility's infection control plan, which includes cleaning and sanitization procedures. Interviews revealed that housekeeping staff clean and sanitize the facility. Management indicated there have not been any recent diagnoses of infectious disease or any residents on isolation, therefore, regular cleaning has been completed and no enhanced cleaning protocols have been necessary. LPA and QA observed the facility's laundry room, which does have separate areas for clean laundry and dirty laundry, which complies with regulation. Staff interviewed did state that resident laundry is commingled during the washing process for efficiency purposes, but that at no time is dirty laundry mixed with clean laundry just that multiple residents' laundry is washed together. Staff also stated that if a resident is on quarantine, their dirty laundry is bagged and washed separately from other residents. 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.

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