Complaint Investigation Report

Prior to the surgery, R1 required minimal assistance with activities of daily living (ADLs), primarily with showering. However, following the surgery, R1 required significantly increased assistance with ADLs due to decreased mobility and drowsiness associated with newly prescribed medications. On 11/11/2025, R1’s responsible parties and former Executive Director (ED) Aaron Mayes held a care plan meeting to discuss R1’s anticipated increased care needs following the surgery. During the meeting, a temporary care plan was developed to address these changes. Interviews confirmed that notice of R1’s increased care needs was posted in the medication room for staff reference; however, no formal staff meeting or written notification was conducted to ensure staff were informed of the changes. During the initial visit on 12/03/2025, ED Mayes and staff confirmed that several staff members had not seen the notice posted in the medication room regarding R1’s change in care needs. Staff further stated that the required two-hour checks intended to begin following the surgery were not consistently implemented until staff became aware of the updated care instructions. LPA was unable to obtain R1’s service plan that was in effect prior to the surgery due to management and organizational changes at the facility. However, LPA obtained a service plan dated 12/03/2025. The service plan documented R1 as a Level 3 out of 5 care and indicated that R1 required assistance with toileting and incontinence care throughout the day and night (moderate assistance), no assistance with transferring, verbal reminders and cueing for mobility (minimal assistance), hands-on assistance with bathing (moderate assistance), support with dressing and selecting appropriate clothing (moderate assistance), and no assistance with grooming. Staff, R1, and R1’s responsible parties stated that prior to the surgery, R1 was able to independently perform all ADLs except showering. Following the surgery, R1 required frequent monitoring and assistance with all ADLs. Staff and ED Mayes acknowledged there had been a “miscommunication” regarding R1’s increased care needs. On 12/01/2025, ED Mayes conducted a mandatory meeting and in-service training for all medication technicians and caregivers on all shifts regarding staff responsibilities to ensure residents’ care needs were properly addressed. LPA also observed logs documenting that R1 received two-hour checks throughout the night on 12/01/2025 and 12/02/2025. The facility was unable to provide earlier logs due to the management change that occurred on 12/01/2025. Based on interview and record review, the allegation “Staff did not ensure resident's care was increased following resident's surgery” is deemed SUBSTANTIATED at this time. ED Mnoyan was unable to remain for the remainder of the visit and designated Admissions Coordinator Stephanie Sarabia to sign the report. Report was reviewed telephonically with the ED. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. Appeal rights and a copy of the report provided.