complaint·September 29, 2023

Resident suffered multiple falls resulting in injuries . Interview with staff revealed that R1 had six falls while living at the facility in which four falls resulted in injuries or minor injuries. However, after R1’s fall on 5/22/2022, the facility raised R1’s level of care from a two to a four which increased resident checks to eight times, R1 is checked every 30 minutes due to fall risk, and fall alarms was installed in R1’s room. Resident was not provided assistance with toileting needs Interview with staff indicated that toileting needs are checked at least every 2 hours. Staff have not witnessed resident's toileting needs were not met. Resident was not provided assistance with showering . Interview with staff revealed that R1 would sometimes refuse showers and staff come back at a later time to assist R1 with showers. Staff stated when a resident refused showers, it would be documented on the progress notes. Inadequate staffing to meet the needs of the residents in care . LPA reviewed staff scheduled and observed AM shift have 4-5 caregivers and 1 med tech, PM shift have 4 caregivers and 1 med tech, and NOC shift have 2 caregivers and 1 med tech. Interview with staff revealed that besides the caregivers and med techs, a manager is on duty for both AM and PM shift seven days a week. Staff did not respond to resident's call bell . LPA reviewed a sample of resident's pull cord records and observed pull cord incidents from R1 were responded by facility staff. Resident cannot easily use pull cord . LPA observed R4 demonstrated how to pulled on the pull cord beside the bed and was able to pull the pull cord. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.