complaint·April 22, 2025

Staff leaves resident in bed for an extended period of time. On the allegation that staff leaves resident in bed for extended periods of time, it is the concern of the reporting party (RP) that the staff do not assist residents to get up from the bed. Residents are kept in bed all the time except when residents receive physical therapy (PT) twice a week. To investigate the allegation, the LPA interviewed residents, and the interviews revealed that the facility has only one staff; consequently, the staff does not assist residents in getting up from bed. The LPA interviewed the staff (S1), and the staff stated that they can only assist residents with repositioning and transferring from bed to wheelchair, residents receive PT twice a week and assist residents with mobility. Record review revealed that residents in care are receiving PT twice a week for mobility. Based on the interviews and record review, although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Staff does not attend to resident in a timely manner. On the allegation that staff do not attend to residents in a timely manner, the concern of the RP that the facility staff do not attend to the residents when they call for help, and when the residents ask for something, the staff take a long time or ignores the request. The residents’ interviews revealed that one resident stated that when they ask for a condiment for food the staff often ignore their call and requests, or takes a long time (45 minutes to provide the condiment). The staff’s interview revealed that they do attend to the requests of the residents and denied ignoring the residents’ calls for help. Based on the information obtained through interviews, although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Continues on LIC 9099 C... page 3. Pg. 3. Staff does not provide adequate meal service to resident. On the allegation that staff does not provide adequate meal service, it is the concern of the RP that the staff only serves the same meals over and over, sometimes sandwiches for dinner or a bagel and sometimes macaroni. Residents’ interviews revealed that if they fall asleep during one of the three meals the staff won’t wake them up, and alleged that they did not get to eat because they fell asleep. One resident stated that the meals are ‘ok’. The staff only provides three meals, cold cereal in the mornings, and no snacks unless the residents ask for a snack. LPA Urena conducted a physical plant tour of the kitchen, and the facility appeared to have sufficient and a variety of foods for the residents in care. The staff’s interview revealed that they prepare three meals a day for the residents in care, which include vegetables, meat and fruit. Breakfast includes oatmeal, cereal, and drink. Staff stated that they provide snacks, but only if the residents request a snack. The snack typically consists of cookies. Although the allegation may have happened or is valid, based on the interviews, and observation, the staff provided at least three meals during the day, and a snack when requested by residents in care. Therefore, the allegation is deemed Unsubstantiated at this time. Staff does not administer medications as needed. On the allegation that staff does not administer medications as needed, it is the concern of the RP that the OTC pain medication is sometimes not given when asked for. To investigate the allegation the LPA conducted medication audit, and interviewed residents in care. The medication was properly documented in the Centrally Stored Medication and Destruction Record form (LIC622). The residents interview revealed that sometimes they will ask for the over-the-counter pain medication and the staff will not provide as requested. One resident stated that they get their prescribed medications on time. Although the allegation may have happened or is valid, based on the interviews, and observation, the staff provided prescribed medications as prescribed by the physician. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted. Copies of the report were issued. Staff does not ensure resident's grooming needs are met. On the allegation that staff does not ensure resident’s grooming needs are met, it is the allegation of the RP that they had observed residents’ hair being hair knotted and tangled from not being brushed, and residents’ diapers are not being changed frequently enough. Residents’ interviews revealed that they get a diaper change only twice a day, and not at night. They must sleep on their wet/soiled diaper throughout the night. The staff’s interview revealed that they change diapers twice a day and when the residents request at night. Based on the information obtained through interviews, the staff is not following regulations based on the staff’s answer on how many times the staff attend to the residents’ needs for a change in diaper. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal rights were issued.