Complaint·September 11, 2025

The investigation revealed the following: Allegation: Facility staff do not ensure resident is provided adequate supervision resulting in resident having multiple falls while in care. It is being alleged that a resident has sustained multiple falls at the facility resulting in resident having multiple bruises on their arms, and face. On 07/28/25, between 10:20 AM and 12:00 PM, LPA conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff stated that they provide adequate supervision for residents to prevent any fall and/or injuries. 3 out of 5 staff said they did not know if R1 fell on 07/19/25, and 2 out of 5 staff stated R1 did fall. 3 out of 5 staff stated that R1 does not fall frequently. 5 out of 5 staff stated that residents are checked on every 2 hours and as needed. On 07/28/25, between 1:05 PM and 2:00 PM, LPA conducted interviews with R2-R4 and attempted to interview R1 but was unable to as R1 is in the hospital. On 09/11/25, between 1:00 PM and 1:45 PM, LPA conducted interviews with R5-R6. Of those interviewed, 5 out of 5 residents said they weren’t aware of a resident sustaining multiple falls. 5 out of 5 residents reported feeling safe when being assisted by staff. 5 out of 5 residents said they are satisfied with staff and the services provided to them. On 09/11/25, LPA conducted a review of records and revealed the following: Physician’s Report (dated: 07/09/25) noted that resident is non-ambulatory and will participate in unsafe wandering and will try and get out of bed without reason and/or physical power. An Unusual Incident/Injury Report (dated: 07/21/25) reported that on 07/19/25, at around 05:30 AM, R1 was found on the floor with a laceration on left eye area. R1 was assessed, and first aid was provided. R1’s responsible party was then notified, and staff continued to observe R1 for any change in condition. Then at 08:10 AM, R1 was observed bleeding from nose, and 911 was called and resident was transported to hospital. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the 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. An exit interview was conducted, and a copy of the report along with appeal rights was provided to Administrator, Steve Cho. The investigation revealed the following: Allegation: Staff does not ensure resident receives sufficient continence care resulting in resident being left in multiple soaked diapers. It is being alleged that a resident came into the emergency department wearing 3 diapers that were all soaked through. On 07/28/25, between 10:20 AM and 12:00 PM, LPA conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff stated that they did not know if the above allegation happened. 5 out of 5 staff said they do not put more than one diaper on a resident. Interview conducted with S1 revealed that after conducting their own investigation, they became aware of two staff admitting to putting more than one diaper on a resident, and that they have taken the necessary disciplinary action. On 07/28/25, between 1:05 PM and 2:00 PM, LPA conducted interviews with R2-R4 and attempted to interview R1 but was unable to as R1 is in the hospital. On 09/11/25, between 1:00 PM and 1:45 PM, LPA conducted interviews with R5-R6. Of those interviewed, 5 out of 5 residents said they weren’t aware of a resident sustaining multiple falls. 5 out of 5 residents reported feeling safe when being assisted by staff. 5 out of 5 residents said they are satisfied with staff and the services provided to them. Based on record reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. Title 22, Division 6 Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the report along with appeal rights was provided to Administrator, Steve Cho.