complaint·February 14, 2023

On the allegation that the ‘Resident fell, and was left on the floor until the following morning’; it is the complainant’s concern that R1 had fallen during the night, and was not found until the med tech passed the next morning. On 02/07/2023, LPA Urena conducted record review of documents submitted to LPA Basili during the initial investigation by the complainant and the facility. The record review submitted by the complainant revealed that the facility verified via an Incident Report that R1 had indeed fallen on 09/10/2020 and was found on the floor on 09/11/2020 by a facility staff. LPA Urena conducted six (6) resident interviews pertaining to the allegation, and five out of six the interviews revealed that although the rooms have a call system, it may take staff at least 30 minutes to respond to the call/light. Additionally, the residents’ interviews revealed that the facility often experiences staff shortage, and although caregivers are very nice, they may not always respond in a timely manner. The record review of R1’s file revealed that the pre-placement appraisal dated 05/22/2020 states that R1 is non-ambulatory due to R1’s use of a walker, and that R1 requires assistance when using the toilet. Based on the information obtained through record review, and interviews; there is sufficient evidence to support the allegation that the resident fell, and was left on the floor until the following morning. Therefore, this allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Citations were issued. Exit interview conducted. A copy of the report and appeal rights were provided. On the allegation that the ‘Facility staff does not provide basic needs to residents’; it is the concern of the complainant that the facility does not provide supports for individuals based on their need. Someone to take care of the basic needs of the residents - such as attending medical appointments outside the facility. To investigate the allegation, LPA Urena conducted staff and residents’ interviews from 12:30 to 2:15 p.m., and record review pertinent to the allegation at 1:15 p.m. The LPA interviewed seven residents, and four out of seven stated that they typically go to the front desk to let them know of an upcoming appointment, and the staff will book the van for them for the date and time of the appointment. Two out of the seven residents stated that the staff will book their appointments for them. Two out of the seven residents stated that they will use other means of transportation such as Access, or public transportation. Residents stated that the facility staff who takes them to the appointments usually waits for them, but there are times when the staff, will come back to pick them up once the appointment is over. The LPA requested copies of the Chauffer Service Sign-Up sheet, and the LPA was able to verify through interviews that the residents on the sign up lists were taken to their appointments. The staff’s interview revealed that residents typically let the front desk person of their upcoming appointments and sign up for the van transportation service. Based on the information obtained through record review, and interviews; there is insufficient evidence to support the allegation that the facility does not provide supports for individuals based on their need. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview was conducted with the facility representative. A copy of the report was issued.