Complaint Investigation Report

During interviews with Residents R1-R12, were asked if they feel staff meet reporting requirements, informing responsible party or physician, twelve (12) out of twelve (12) stated they feel staff meet reporting requirements.

During an interview with a resident’s family member W1, was asked if the facility stated the POA was not made aware of the incident until they visit the facility on 04/15/2026.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

Allegation: Staff do not ensure resident was provided medical care

The allegation alleges that a resident was not sent to the hospital to be evaluated after not eating meals and being observed with feces in their mouth.

During record review, LPA received and reviewed two Internal Resident Incident Reports, one is dated 04/13/2026 at 3:20am that indicates R1 was observed with feces in their mouth. Staff attempted to assist R1 and R1 was combative and went back to sleep. Staff attempted to assist R1 again 10 minutes later and R1 was still combative and went back to sleep. When AM shift arrived, Staff tried to assist with brushing teeth and R1 was combative. The second Internal Resident Incident Report is dated 04/13/2026 at 3:15am, S2 was informed R1 was observed with feces in their mouth and if R1 should be sent out. S2 informed Staff that R1 could be sent out for altered mental status but may be returned right away if R1 has a diagnosis of dementia. Under Action Taken indicates S2 to follow up with Primary Care Physician (PCP) and family. LPA observed in the Contact Made section there was no indication if the Physician or Responsible Party were notified. Additionally, LPA received and reviewed St. Mary Medical Center – Long Beach Discharge Instruction Document (dated 04/17/2026) that indicates R1 was examined due to abdominal pain and acute chest pain during respiration.

During interviews with Staff S1-S7, were asked if residents receive medical care when needed, seven (7) out of seven (7) stated resident receive medical care when needed.

During interviews with Residents R1-R12, were asked if staff ensure they receive medical care when needed, twelve (12) out of twelve (12) stated yes they receive medical care when needed.