Complaint Investigation Report

Allegation: Staff did not properly report incidents involving residents. It is alleged that facility staff did not submit incident reports within reporting requirements time frame. According to information obtained, multiple incident reports and/or death reports were not submitted to CCLD within 7 days. Based on staff interviews, in December 2025 the Wellness Director resigned. The Resident Care Coordinator was appointed facility designee on December 25, 2025. According to staff, the Wellness Department team and Executive Director are responsible for oversight of the medication room and Wellness Department responsibilities i.e., submitting incident reports. Based on record review, the findings revealed that from December 2025- February 2026 a total of 30 incident reports and one (1) death report were submitted late; not within Title 22 reporting requirement of 7 days. Therefore, there is sufficient evidence to support the allegation.

Allegation: Staff do not meet and have updated services plans for the residents. It is alleged that multiple residents' service plans are not updated despite documented changes in condition, and staff are not following existing service plans. For instance, facility procedure is to develop a service plan within 48 hours of move-in date, and routinely update every 3 months and/or as needed. Personnel and licensee were interviewed. The findings indicate that the Executive Director, Resident Care Coordinator, and Wellness Director are accountable for the service plan assessments. The Resident Care Coordinator is responsible for completing services plans. Once the service plan is completed August Health electronic health record (EHR) software automatically send the service plan to the resident's authorized representative/responsible party for review and signature. Staff stated that some residents service plans are not completed because their authorized representative has not signed it electronically. On February 13, 2026, ten (10) August Health service plans were audited by LPA. The findings indicate that residents (R1- R4's) service plans were completed late and/or there was no service plan in the file. For example, resident (R2) moved in to the facility on September 26, 2025 and their service plan was completed on February 1, 2026. The allegation is supported.