Complaint Investigation Report

Report does not indicate location where R1 was at the time. The report further revealed that pendant of R1 was responded to by staff at 6:41pm indicating a wait time of 48 minutes and 52 seconds. Based on review of video recording it was revealed that R1 fell out of her wheelchair near her bed at 6:35pm during an attempted self transfer with wheelchair appearing to be partially on top of R1. A second video revealed a caregiver entering the room at 6:43pm to begin assessing R1 after noticing R1 on the ground. Interviews conducted further confirmed a wait time of approximately 48 minutes. A review of R1’s physician’s report and appraisal form indicated R1 experienced disorientation and required assistance for activities of daily living including incontinence care and was under hospice care at the time of the above incident. Based on the above evidence reviewed, it is determined that staff did not provide adequate supervision for R1 on 2-10-2026. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Staff did not administer medications to a resident. LPA conducted interviews and record reviews as noted above. Record reviews revealed a self-medication management acknowledgement was signed by R2’s responsible person and Administrator to indicate R2 can manage own medication. A physician’s report for R2 dated 1-23-2026 stated R2 is unable to manage own medication and required assistance. A census report indicated R2 was in a hospital setting and not at the facility from the dates of 1-9-2026 to 1-29-2026. Based on review of medication log sheet for January 2026 it was indicated that R2 did not receive four medications as ordered between the dates of 1-30-2026 and 1-31-2026. Interviews conducted further confirmed the information revealed in the log sheets. No additional evidence existed which proved R2 ever received these medications. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Citations are issued under Title 22, Division 6, and Health and Safety Code, Chapter 3.2, and noted on LIC 9099D. An exit interview was conducted with Administrator, and a copy of this report was provided. LIC 811 and appeal rights provided.