complaint·September 21, 2021

Regarding the allegation that lack of supervision resulting in resident #1 sustaining multiple falls, the investigation consisted of Interview(s) with Administrator, Staff, and review of Resident #1's file. The investigation revealed that resident #1 was found on floor in her room by night shift staff on 12/4/19. However, Administrator stated that it was not confirmed that resident #1 fell. Resident #1 was observed to be on her knees and holding onto the bed rails by staff. Resident #1 was unable to state what happened. Resident #1 was assessed, and was not observed to have any scratches or bruising to body. Facility submitted a Special Incident Report as required. Administrator and Staff interviewed stated that Resident #1 did not sustain any falls while residing at the facility. LPA was unable to interview Resident #1, as resident no longer lives at the facility. Regarding the allegation that Facility is over medicating resident #1, the investigation consisted of Interview(s) with Administrator, Staff, and review of Resident #1's file, including Medication Administration Record(s). The investigation revealed that the facility was administering medications as prescribed by Resident #1 physician(s). Administrator and Staff interviewed denied that facility was over medicating Resident #1. LPA was unable to interview Resident #1, as resident no longer lives at the facility. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Administrator, Linda McIntosh.