complaint·April 21, 2022

The investigation revealed of the following: Allegation#1 " Resident had unexplained injury" it was alleged Resident #1 received a black eye while living at the facility. Interviews with staff indicated the resident never had a black eye while residing at the facility. Interviews with staff revealed the resident was aggressive and would hit staff but did not have self injurious behaviors. Staff stated they never witnessed any staff hit the resident or hear about a staff hitting the resident or any other resident. LPA also interviewed residents and residents families and reported residents they never had any unexplained injury and the staff take good care of them and they are doing their best for the residents. Allegation#2 " Staff did not notify authorized representative of residents injury" it was alleged the facility did not notify the responsible party of Resident #1 after sustaining a black eye at the facility. Interviews and records reviewed indicated the resident did not have a black eye, therefore the facility never contacted the responsible parties. A photograph was provided of the resident with the alleged black eye and LPA could not verify if it was the angle of the picture or a black eye. LPA also interviewed the residents and residents families and reported the facility staff always notified the authorized representative with any concerns of the residents. The staff are on top of it and they always provide good care to the residents. They have no concerns or complaints about the facility. Based on the additional residents interviews conducted, the complaint investigation findings remain the same: UNSUBSTANTIATED. Exit interview was conducted with the Assistant Administrator Laura Hernandez and a hard copy was provided. Interviews revealed the resident was put in the Gerry Chair with the table tray during meals and while caregivers put back the dishes back in the kitchen. Per interviews, the chair was used because it helped the resident stay more calm while eating. Interviews with staff also revealed the chair was used to elevate the residents legs when they were swollen. Staff stated they would put the resident in the chair for about an hour to help his legs. Interviews and records showed the Gerry Chair did not belong to the resident and belong to other residents at the facility who were on hospice and had physicians orders for the chair. Community Care Licensing (CCL) never received a request/plan for approval prior to using the Gerry Chair. It is unclear how long the resident was left in the chair during the day or if it was used for other than meal time and leg elevation. LPA received a photograph of the resident in the Gerry chair with the table tray on, in what appeared to be a resident room at the facility. The table tray did not have any food on it. The residents file revealed the resident had Dementia and needed assistance with several of the residents Activities of Daily Living (ADL's). In an appraisal conducted on 7/3/2020, it indicated the resident was unable to communicate clearly. While living at the facility he became aggressive towards staff and the facility later determined they could not care for the resident due to the residents behaviors. Based on the interviews conducted and the prior investigation, the complaint investigation findings remain the same: SUBSTANTIATED. Exit Interview Conducted and a copy of the report was provided to Assistant Administrator Laura Hernandez.