Complaint Investigation Report

Regarding the allegation: 1.) Staff did not seek timely medical care to resident in care. It was alleged that an unnamed resident had a fever in February 2025 and that staff did not seek medical treatment for the resident as the resident passed away on 02/27/2025 and complainant alleged that delay in medical care could be a factor. Per record review, only one (1) resident passed away on 02/27/2025, Resident #1 (R1). LPA Peraldi reviewed resident records for R1 and it was noted that R1 was admitted to the facility on 07/30/2021, was placed on hospice services on 07/11/2023, and had no record of hospitalizations during the alleged period. Interviews with staff and the ED did not reveal any concerns regarding staff not seeking timely medical care to residents as staff were aware of protocols and procedures and when to call emergency services. Record review revealed that on 02/25/2025, R1 had orders from their hospice agency to have daily nursing visits for five days for symptom management. Interviews with the ED and Wellness Director, Gloria Morales stated that R1 did not get hospitalized in February 2025. Due to lack of information provided by the complainant and lack of records of fevers or hospitalizations during the alleged period, the information obtained during the investigation did not include evidence sufficient 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.

Regarding the allegation: 2.) Staff did not ensure resident's room was kept free of ants. It was alleged that an unnamed resident had ants on their body when staff would change their diaper. All staff interviews revealed that ants had not been observed on residents’ bodies or in residents’ rooms, however three (3) out of eighteen (18) interviews with staff revealed that they had heard of ants on a resident in the past. Specific details or time frames of the incidents could not be provided. During physical plant tours conducted on 03/12/2025, 03/21/2025 and 08/20/2025, the LPAs did not observe ants or insects inside resident rooms. The information obtained during the investigation did not include evidence sufficient 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.

Regarding the allegations: 3.) Staff did not ensure sufficient hygiene supplies were available at the facility to meet resident's care needs. 4.) Staff did not ensure resident's bedding was kept clean. It was alleged that the facility had insufficient amount of basic hygiene supplies which led to residents having urine-soaked bedsheets. Interviews with staff revealed that families provide majority of incontinence and hygiene supplies, however, the facility does have a storage room which holds incontinence and hygiene supplies if needed. Continued on LIC 9099-C.