complaint·August 3, 2022

interview with Resident #1 due to its non-verbal communication. LPA/RA Ceniceros toured the facility to observe Resident #1's bedroom door next to the hand rail, it appears that all of the resident's bedroom door is adjacent to a hand rail (photograph). The photograph provided did not document a room number on the door; therefore, it could not be determined if Resident #1's bedroom door had been tied to the hand rail on or about 12/30/21. Resident #1 receives 1:1 care; therefore, the resident has a 24/7 caregiver at all times. Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Staff locked resident in their room is found to be UNSUBSTANTIATED. Regarding Allegation #2: this investigation revealed based on Resident #1's records review and interviews conducted (between 12:30 p.m. to 2:45 p.m.) of Administrator and Staff #2 - Staff #5, Resident #1 receives 1:1 care 24 hours a day/7 days a week based on the December/January 2021 Calendar Year and Weekly One-on-One Schedule (dated 12/26/21 to 01/01/22), Resident #1 had 1:1 staff assigned to its care. In addition, the facility is contracted with Angel Care Staffing Agency should the facility experience a staffing shortage. On the date in question (12/30/21), Resident #2 stated that it didn't mind Resident #1 coming into its room to get candy or cookies or a soda because that's what it's there for to share with the residents. Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Staff did not follow resident's care plan is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to Staff #2 (S2: Martha Uribe Rosas, Facility Manager); as Administrator (Pamela Ogot, MBA) was unavailable.