complaint·September 15, 2023

The investigation revealed the following. Regarding Allegation(s): Resident sustained multiple pressure injuries while in care of the facility - It is alleged R1 sustained multiple injuries while in care of the facility. R1 was admitted into the independent living unit of the facility on 8/18/20. Records review revealed that R1 sustained three (3) unwitnessed falls in R1 accommodation from June 2023 through July 2023. On 6/3/23, staff reported R1’s had an unwitnessed fall, and no injuries were noted. On 6/28/23, staff reported R1’s unwitnessed fall, and no injuries were noted. On 7/23/23, staff reported R1’s unwitnessed fall and injuries were noted. Doctor’s Order Sheet signed and dated by R1’s physician, indicates R1 is okay to return to accommodation. LPA Ramirez reviewed Pomona Valley Hospital notes dated 8/1/23 and no observations of pressure injuries were noted on history of present illness. LPA Ramirez could not locate any documentation or staff interviews indicating R1 suffered from any pressure injuries prior to unwitnessed falls. Four (4) out of four (4) staff interviewed deny this allegation. R1 denied this allegation however, R1 could not articulate what a "pressure injury" is or how such injury can occur. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Staff did not respond to resident's call for assistance- It is alleged that facility staff did not respond to R1’s accommodation after R1 pushed panic button. On or around 8/1/23 at 10:14 am, R1 was discovered by staff wedged in between side rail and bed. According to staff interviewed, R1 was wearing alert pendant when R1 was discovered on 8/1/23. Per S1 interview, R1 was wedged in an angle that prohibited R1 from accessing pendant around neck. On 7/31/23 at approximately 9:51 pm, R1 pushed alert pendant. At 10pm, staff responded and noted R1 sitting on floor and indicated that R1 fell. R1 stated that no injuries and was assisted back to bed. On 8/15/23, LPA Ramirez toured R1’s accommodation and tested emergency pull cord in bathroom. Facility staff responded within 1 minute by calling R1’d bedside phone. LPA Ramirez reviewed facility Device Activities Report dated 8/1/23 and could not locate a request for assistance by R1. Facility staff did respond to a request for assistance on 8/1/23 to R1’s accommodation due to staff finding R1 wedged in between bed and half rail. Four (4) out of four (4) staff interviewed deny this allegation. Interview with R1 revealed, R1 recalled pushing pendant but stated staff did not arrive. R1 later stated during interview that R1 could not reach pendant due to left arm being wedged in between bed and rail. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . See 9099-C for continuation. Staff are not meeting resident's hygiene needs- It is alleged R1 appeared disheveled and lacked proper hygiene. Physician’s report dated 5/20/20 indicates R1 is ambulatory and does not require bathing/grooming assistance. On 10/14/22, R1 signed Addendum to Care and Residence Agreement that provides additional care to R1 with personal care, escort, housekeeping, errands, pet care, and additional services at R1’s request. LPA Ramirez reviewed staff response notes for the month of July 2023. LPA Ramirez counted at least eleven (11) documented instances of R1 requesting staff assist with bathing and staff responding to R1’s request. Four (4) out of four (4) staff interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies are being cited during visit. Exit interview was conducted and a copy of this report was provided via email due to printer problems.