Inspector’s narrative
What the inspector wrote
Service Plan, Healthcare Provider Communication, pendant Device Activity Report, and Staff Training Logs.
The investigation revealed the following:
Allegation: Staff did not respond to residents calls for assistance in a timely manner resulting in resident falls
The allegation alleges that a Resident pressed their call button for assistance and when staff did not come the resident got up and had a fall.
LPA received and reviewed pendant Device Activity Report and observed on 02/08/2025 at 11:07:21PM R1 pressed their pendant, it was cleared at 11:31:54AM, taking staff a total of 24 minutes and 33 seconds to respond. Additionally, LPA observed R1 pressed their pendant at 2:37:13AM, that was cleared at 3:00:25AM, taking staff a total of 23 minutes and 12 seconds to respond to the call. R1’s arrival to the Emergency Room was on 02/09/2025, at 3:46AM. Additionally, LPA reviewed a Special Incident Report (SIR) for Resident R11, that states R11 had a fall on 02/14/2025. LPA reviewed the Device Activity Report and observed on 02/14/2025 at 8:57:29AM R11 pressed their pendant, it was cleared at 9:27:52AM, taking staff a total of 30 minutes and 23 seconds to respond. LPA received and reviewed staff Charting Notes for R11 that states on 02/14/2025 Resident had an unwitnessed fall approximately around 9:15AM and Resident was found on the floor.
During interviews with Staff S1-S10, were asked if any residents experienced a fall
while waiting for assistance, two (2) out of ten (10) Staff stated residents have experienced a fall while waiting for assistance.
During interviews with Residents R2-R9, were asked if they experienced a fall due to lack of assistance, five (5) out of eight (8) stated they have not experienced a fall due to lack of assistance.
During interviews with Witnesses (W1 and W2), were asked if a resident experienced a fall due to lack of assistance, one (1) out of two (2) stated a resident experienced a fall due to lack of assistance.
During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.
An exit interview was conducted with Executive Director, Jose Saladana, and a copy of this report and the Appeals Rights was provided.
Service Plan, Healthcare Provider Communication, pendant Device Activity Report, and Staff Training Logs.
The investigation revealed the following:
Allegation: Staff are taking resident’s incontinent supplies.
The allegation alleges a staff member came into a resident’s room and left with a trash bag full of their incontinent supplies and supplies are needing to be replaced more frequent.
LPA received and reviewed the list of residents who receive incontinent assistance and have supplies delivered, brought in, or supplied by the facility. During the facility tour, LPA observed an ample supply of incontinent supplies to be used for residents if they run out of their supply of incontinent products.
During interviews with Staff S1-S10, were asked if staff take other residents incontinent supplies to use for other residents, ten (10) out of ten (10) stated they do not take other resident’s incontinent products to use on other residents.
During interviews with Residents R2-R9, were asked if staff have taken their incontinent products from their room to use on other residents, one (1) out of eight (8) stated they have seen staff take their incontinent products from their room.
During interviews with Witnesses W1 and W2, were asked if any of their resident’s incontinent products were taken to use on other residents, one (1) out of two (2) indicated their resident said staff has taken their incontinent products from their room.
Allegation: Staff do not check on resident every 2 hours.
The allegation alleges staff do not check on resident every 2 hours.
During file review, LPA received and reviewed Healthcare Provider Communication, for Resident R1, on 12/05/2024 LPA observed the provider from Torrance Memorial Medical Center indicates the Outcome of Visit: “Check in every 2 – 3 hours for toileting. LPA received and reviewed Resident R1’s Assessment Summary that indicates R1 “is at moderate risk for falling according to the Fall Risk Assessment.” LPA received and reviewed Resident R1’s Care Plan dated 01/10/2023, indicates R1 has had a fall with injury in the past, the Goal is to minimize fall risk by “supervision, not leaving me unattended”, and the Intervention is to “Check on me at frequent intervals to see if I need any assistance.”
During interviews with Staff S1-S10, were asked how often they check on residents, five (5) out of ten (10) stated they check residents every hour, three (3) out of ten (10) stated they check every 2 hours, and two (2) out of ten (10) stated they check every 30 minutes. Additionally, during interviews, four (4) out of ten (10) stated for residents who are a fall risk they check on them every 30 minutes.
During interviews with Residents R2-R9, was asked if staff come and check if they need assistance throughout the day, eight (8) out of eight (8) stated staff check on them a few times a day.
During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is
unsubstantiated
.
An exit interview was conducted with Executive Director, Jose Saladana, and a copy of this report was provided
