The Meridian at Anaheim Hills.

During an interview with Executive Director Ray Pellicer, caregivers are instructed to notify med tech if they observe any skin concerns. Med techs report to the Memory Care Director Ira Lustina, and Ira will contact the doctor and family. When Memory Care Director Lustina was asked about facilities protocol when it comes to pressure injuries, she said, Med techs will report to me… if it’s a stage one hospice will provide a skin barrier cream or ointment. If it’s stage two, hospice will come and treat the wound. If the residents on Home Health, they will come treat it as well. If it’s unstageable, we send them out. We report it to the doctor first then they will order for us to send them to the hospital or skilled nursing. We’re not allowed to treat or stage a pressure wound so we report it to the doctor first. Document review was consistent with the information gathered during interviews. The care team would reposition residents who had pressure wounds, document the time the resident was repositioned and make additional notes regarding status or condition of the resident (what side they are laying on). The documentation was consistent and it was documented the same over an extended period of time. The documentation style was consistent and followed a pattern that was used by all different staff, and used on all different residents, Residents 1 (R1), Resident 2 (R2), and Resident 3 (R3). All three residents were on hospice and were receiving wound care. Regarding the allegation: Facility staff did not notify residents family about pressure injuries During the investigation 0 of 17 individuals provided any information or evidence that supports the complaint allegation. Based on interviews, record review, and due to the lack of information provided when the complaint was filed, much of the information gather contradicts the complaint allegation. During the investigation all five staff members who were asked about the allegation provided a consistent response and it was clear the staff understood their responsibility and know how to respond to pressure injuries appropriately. When the executive director was asked how staff are trained to respond to pressure wounds, executive director stated, the med tecs will report to Memory Care Director, and [The Memory Care Director] will call the doctor, family, and get a treatment order. Continued on LIC9099C pg 2 of 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The Memory Care Director Lustina was asked the same question about how staff respond when they see a pressure injury and she said, Med techs will report to me… if it’s a stage 1 Hospice will a skin barrier or ointment if it’s stage 2 Hospice will come and treat the wound if they’re on HH they will come treat it as well. If it’s unstageable, we send them out... we report to the doctor first then they will order for us to send the resident to the hospital or skilled nursing. We are not allowed to treat or stage a pressure wound so we report it to the doctor first. According to Staff 3 (S3), if it’s more than stage one, we usually do home health or if they’re on hospice they do the care. We turn the residents every two hours… If the pad comes off, we call hospice to change it because we can’t. If it’s stage one and they prescribe cream, we can apply the cream, but when the wounds opens, we contact the doctor. Document review revealed, facility staff documented consistently and took good notes on each resident. Facility staff would document when residents were repositioned, information about the pressure wounds when necessary, document the time the resident was repositioned, and make additional notes regarding status or condition of the resident during the required check. It was clear the facility uses an effective documenting process and the documentation style was consistent that remains consistent with the different staff, as well as with different residents. A review of resident records for R1, R2, and R3 who were all receiving wound care was all documented the same way over an extended period of time. Facility staff also ensured outside providers like Home Health and Hospice providers were required to fill out outside agency forms with contact information and notes about the residents’ condition and care. Providers fill out forms and document the status of residents’ condition after each visit, consistently. Regarding the allegation: Staff locked residents in their bedroom 0 of 17 individuals provided any information or evidence that supports the complaint allegation. All staff who were asked about residents being locked in their room denied the allegation. According to Executive Director the opposite is happening and Executive Director states, if anything the residents are out of their room too much. Memory Care Director Lustina strongly denied the allegation and said, we don’t lock residents in their room… How can we lock them in if the lock is on the inside. Continued on LIC9099C pg 3 of 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staff 3 (S3) said, “No.” when asked the question. S3 was then asked about whether there have been complaints or concerns from family members and S3 denied there had been any complaints or concerns from family members. Staff 5 (S5) said, “No.” We never lock doors. They’re (residents) the ones who lock their door. Like this morning the door was locked for one of the residents. During the investigation, interviews were conducted with six different family members of residents in the memory care unit. All of the family members denied residents are locked in rooms. However, a couple family members did acknowledge they were informed the room doors are locked for a couple days if one of the residents display wandering behaviors and begin to enter rooms that don't belong to them. Another family member stated they were informed they doors are locked if another resident is entering resident rooms. All other family members denied the allegation and said no when asked if residents are locked in their rooms. One family member said their loved one's door is always open. Regarding the allegation: Facility staff did not adequately supervise residents during showers 0 of 17 individual were able to provide any supporting details or information that supports the complaint allegation. All the staff who were interviewed denied the allegation and provided information the opposes the allegation. According to the Memory Care Director, each care staff has their list of residents on who to shower. Residents in memory care always say no. If they refuse, we come back in an hour, if they refuse we try again later. Memory Care Director also confirmed that a staff member is present at all times when residents are being showered. Staff 3 (S3) was asked about the showering process and said, “I don’t do it much because I’m the med tech.” S3 explained, each shower schedule is twice a week. If the resident is on hospice, the hospice provider administers the shower. S3 explained, if they don’t want to shower, we fill out a paper they refused, and we let the boss know they don’t want to shower. Staff 5 did not provide any information that supports the allegation and said, “We usually give them a sponge bath and get them up if they are not on the schedule for showers. Continued on LIC9099C pg 4 of 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 According to staff 4 (S4), residents have showers at least twice a week. S4 explained, ideally, we try to shower them in the morning… if they have a preference, we try to honor that… If they refuse a shower, we attempt to shower them later. If they refuse again, we endorse the PM shift, and they take over and try and get the shower done then. A family member of a memory care resident, was asked if there were any concerns with the supervision at the facility and the family member, strongly denied, and said, No… No. Based on the information gathered through interviews, document review, and observation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed unsubstantiated.

Based off Resident’s needs and service plan dated April 4, 2025, “resident is independent with most activities of daily living and needs help with PureWick External Female Catheter at night. Female staff assist resident. Resident is alert and able to communicate needs. Resident requires one person total assist with catheter and bathing twice a week”. It was reported that R1 was being showered by Staff member (S1) when they were told to stand up and face the wall while S1 proceeded to wash R1’s back, buttocks and legs with wash cloth. R1 was shocked that S1 would wash them in their private area. It was alleged that after S1 washed backside of R1 they reached around to wash front private area to which R1 felt S1 was being rough. R1 stated that S1 did not say anything while bathing R1 and R1 did not communicate to S1 to stop. Police Department Report dated April 30, 2025, stated that R1 did not report incident until 3 weeks later due to fear of S1 retaliating against them. R1 stated that S1 began cleansing R1’s body and made the statement “We’re going to get nice and clean, we’re going to clean the vagina”. R1 stated the statement made them uncomfortable. R1 stated that S1’s hands were where they shouldn’t belong and stated that S1 began to clean their private area. Police Report also mentioned that R1 stated multiple times “Everything is a blur” and when asked about prosecution for incident, R1 stated that they “wanted behavior corrected, but without incarceration”. Interviews were conducted with seven residents (R2-R8) who also received shower assistance from S1, all stated that they do not have any issues with staff while being assisted with showers and have never been touched inappropriately by staff. Interview with R1 stated that S1 had assisted them twice with showering and first time there was no problems. R1 stated that S1 had assisted with R1’s back, buttocks and legs due to R1 unable to reach area. R1 could not recall if they were sitting in the shower or standing up. R1 stated that S1 had vigorously washed private area and R1 was upset because they did not want s taff to wash private area. R1 stated that S1 assisted with the catheter without any incident. R1 stated that they did not want S1 terminated and stated what they believed happened. R1 stated they were satisfied with how facility handled situation by removing staff member from assisting R1 with bathing. CONTINUED ON 9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Interview with Staff 1 (S1) stated that they only showered R1 twice and stated that before alleged incident, R1 has requested different staff members before to help assist with showers. S1 stated that they have R1 sit on shower chair and helps assist with back, legs and feet. S1 stated that while sitting on shower chair R1 will wash their chest and private areas. S1 stated that they rinse R1 with shower head while R1 uses free hand to rinse off private area without assistance from S1. S1 stated they help assist R1 with the PureWick External Female Catheter which they feel is more invasive due to applying catheter to private extremities. S1 stated that no other residents have complained about them when assisting with care. Interviews with two staff members revealed that S1 was placed on a two day leave while facility conducted internal investigation. Staff stated that S1 was allowed to return to work but was moved to different location to help assist with Activities of Daily living away from R1. Staff interviews revealed that R1’s service plan requires female caregivers to assist with showers. Staff interviews stated that there have been no previous issues with S1. Due to lack of supportive information and inconsistencies of R1’s statements, there is not enough information to support the allegation staff member sexually abused resident while in care. There were no witnesses to incident and R1 is able to communicate how they prefer to be showered. R1 is also able to wash private area without assistance. There is no specific instructions provided on Residents service plan in bathing section other than Resident prefers a female staff member. Therefore, based on interviews conducted and documents reviewed, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted Executive Director Raymond Pellicer and a copy of this report was provided to the facility.

to which staff member assisted R1 after finding resident on floor by kitchen area. Staff assessed R1’s skin tear on left leg and administered pain meds. Facility staff contacted responsible parties and R1 requested to return to room. R1 later that same morning complained of pain, was reassessed by staff and was sent out to St. Joseph hospital for further evaluation. Facility In Service training log dated from January to July of 2024 documents that facility staff have had on site training's for the following areas of care: fall prevention, colostomy care, fatigue, depression, reporting change of condition, diabetes, and preventing injury using proper body mechanics of lifting & transferring. The Facility Residence and Care Agreement documents the types of care services provided to residents such as Living accommodations, laundry, housekeeping, personal supplies, meals, planned activities, transportation, emergency response and fire protection, consultation, round the clock staffing, incontinence care and dementia services. The Care Agreement also covers additional areas of care such as “change of level of care”, “responsibility with yourself” and “risk of falls”. LPA Tirre contacted Emergency Medical Services (EMS) Coordinator Andrew Tran of Orange County Fire Authority to obtain service calls received from facility for requested assistance to residents. EMS Coordinator stated that Orange County Fire Authority (OCFA) looked into the history of facility and stated that OCFA did not receive any calls for service in over a year. LPA Tirre contacted Anaheim Fire and Rescue regarding service calls from facility requesting for assistance to residents. Anaheim Fire and Rescue Emergency Medical Services (EMS) Nurse Educator Jamie Jantzen stated that their department received 25 calls for fall lift assists for 2024 year. On July 31, 2024 Facility Witness contacted Department and did not corroborate allegations stating they were “just rumors and inaccurate information”. During visit on August 6, 2024 LPA did not observe any health and safety concerns while touring facility. Based off information obtained this agency has investigated the complaint. Although the allegations Staff leave the residents unattended for an excessive amount of time and Staff are not providing adequate care and supervision may have happened or is valid , there is no preponderance of evidence to prove the alleged violation did or did not occur , therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Pellicer and a copy of this report was provided to facility.