Complaint·October 25, 2024

Allegation: Lack of supervision resulting resident(s) to fall. It is being alleged that there is a lack of supervision resulting resident(s) to fall. On 08/29/24 between 11am-11:45am LPA Villegas conducted interview with S1 regarding the allegation above, S1 denied the allegation above and reported there has never been neglect as all staff are trained in resident transfers. On 08/29/24 between 11am-11:45am LPA Villegas conducted interview with S2 regarding the allegation above, S2 denied the allegation above. On 10/10/24 between 9am-12pm LPA Villegas conducted interviews with residents 2-5 (R2-R5) regarding the allegation above, 4 of 4 residents interviewed denied the allegation above and reported feeling safe at the facility. R2 has no recollection of falling while receiving care at the facility. On 10/10/24 LPA Villegas was unable to interview R6-R7 due to communication barriers. On 10/10/24 LPA reviewed file for R1, there was no documentation indicating that R1 was a risk fall. On 10/10/24 LPA reviewed file for R2, there was no documentation indicating that R2 was a risk fall. On 07/20/23 CCLD received report regarding a fall R2 had while in dining room chair. Per report R2 lost control of body weight and on right side landing on floor, no pain reported, 911 was called, Administrator and son informed. Allegation : Staff did not allow hospice care to enter facility to provide care to resident(s). It is being alleged that Hospice staff arrived at the facility to provide care and licensee turned hospice staff away. On 08/29/24 between 11am-11:45am LPA Villegas conducted interview with S1 regarding the allegation above, S1 denied the allegation above and reported that during covid the facility would schedule times for the hospice agencies to visit the facility to ensure a bathroom was available and to have support from staff. S1 continued to report that the facility was monitoring the amount of people allowed all at once. On 08/29/24 between 11am-11:45am LPA Villegas conducted interview with S2 regarding the allegation above, S2 denied the allegation above. On 10/10/24 between 9am-12pm LPA Villegas conducted interviews with residents 2-5 (R2-R5) regarding the allegation above, 4 of 4 residents interviewed denied the allegation above and reporting their visitors have not been denied entry. On 10/10/24 LPA Villegas was unable to interview R6-R7 due to communication barriers. 10/10/24 LPA reviewed sign in sheet for the facility and observed hospice agencies visit dates to be documented. LPA Villegas attempted to contact hospice agency on 08/30/24 and 10/10/24 but was unsuccessful. Allegation: Staff refused to provide authorized representative residents plan of care. Allegation: Staff refused to provide authorized representative residents plan of care. It is being alleged that licensee refused to provide plan of care for R1 when requested. On 08/29/24 between 11am-11:45am LPA Villegas conducted interview with S1 regarding the allegation above, S1 denied the allegation above and reported that the facility has never refused to provide care plans when requested. On 08/29/24 between 11am-11:45am LPA Villegas conducted interview with S2 regarding the allegation above, S2 denied the allegation above and reported that if requested, document copies are provided. On 10/10/24 between 9am-12pm LPA Villegas conducted interviews with residents 2-5 (R2-R5) regarding the allegation above, 4 of 4 residents interviewed denied the allegation above. On 10/10/24 LPA reviewed copies of email communication between R1's POA, licensee and hospice agencies, LPA observed that care plan was sent via email on 10/23/23, 11/10/23, and 11/12/23. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Licensee Bessie Coello, and a copy of this report was provided.