complaint·June 17, 2024

However, did not contact emergency respond until family member arrived at around 9:00pm and requested to arrange ambulance transport for R1. Interviews conducted revealed the following, per administrator it is protocol to contact 911 after a resident sustains a fall and complaints of pain. Administrator and wellness director had a corrective action conversation with Med-Aide on duty the day of the incident as med-aide should have called 911 after assessing, checking, and observing resident was in continuous and severe pain. Per staff interview it was reported and observed that R1 was complaining of a lot of pain after the fall and 30 minutes after when checked. Med Aide failed to call 911 or arrange emergency transport after checking the resident self and observing R1 was still in pain. On 6/13/24, Administrator provided an in-service training on “procedure review/medical emergencies/criteria/conditions when to call 911.” Per one of the criteria listed in the in-service training pamphlet provided, “The community summons emergency medical services by calling 911 when the resident exhibits signs and systems of distress… fall with… severe pain…” Per administration a write up will be provided to Med Aide upon returning to work. Per the interviews with staff R1 was demonstrating severe pain and Med Aide fail to contact 911. Therefore, the allegation is substantiated. Based on LPAs interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . Regarding allegation: Staff did not ensure that facility was maintained sanitary. It is alleged there was fecal matter on the resident's bedroom furniture and on carpet. LPA observed R1’s room and observed the room was empty, the carpet looked cleaned with three brown half a dollar coin size stains and strong odor of what could be feces or urine. Per interviews conducted with staff R1 was assisted to clean self after toileting due to cognitive skills. Staff stated to find feces in the floor and/or wall in the morning constantly which were cleaned by staff during the day. Per records reviewed a work order was placed to clean the carpet on 4/16/24 and was completed on 5/13/24. Although the staff stated to clean the stains during the day. Due to interviews, LPAs observation and work order to clean the carpet completed in almost a month the allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . (CONTINUED ON LIC 9099C) Regarding allegation: Staff did not safeguard a resident’s ambulatory devices. It is alleged resident's wheelchair become lost on 6/3/2024 and found on 6/11/2024. Interviews conducted reveal the following: Per administrator, the wheelchair was place at storage and wellness director was aware of the location of the wheelchair. Per Wellness director, once the family inquired about R1’s wheelchair, staff began to search for the wheelchair. Family provided serial number and wellness director searched throughout the facility until it was found in the facility’s weight room. Wellness director was not aware of the family bringing in the wheelchair or of its where about and it is not certain how the wheelchair was place in that room. Document review revealed resident personal property and valuables was blank and had no items listed for R1. Per interviews conducted the facility staff were not aware that R1 had a wheelchair and were only aware of its location once wellness director search for the wheelchair. Therefore, this allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Anabelle Argenal and a copy of this report, LIC 9099D, and appeal rights were provided. However, staff will follow R1 or prompt R1 to use the walker right away. Staff stated that as soon as they will notice R1 was up, a staff will follow right after to provide the walker, while in the common areas. Interviews with residents did not provide information regarding the allegation due to residents’ cognitive skills. Documents review revealed R1’s preplacement appraisal information sheet dated 4/10/24 notes R1 uses a walker and is ambulatory. Per appraisal needs and service plan dated 4/19/24, R1 needs constant reminders to use walker. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Anabelle Argenal and a copy of this report was provided.