complaint·January 15, 2025

Allegation: Staff did not provide adequate care and supervision to a resident. On the evening of 11/3/24, R1 sat on the edge of the shower chair and accidentally fell in the shower and was found at 6:15am the next morning attempting to get up from the bathroom shower floor by S9. S9 went to R1’s room to check on the resident and remind her to come to breakfast. S9 immediately assisted the resident as R1 stated she was cold and stated that she could not reach the pull cord. The responsible party stated that R1 had been shouting for help since 6pm the evening before but no one heard her. Per S9, R1 stated that she did not want to go to see doctor but S9 advised her that she should be checked out by a doctor. S9 promptly called for assistance, and Med Tech S-3 responded immediately. The Med Tech called 911 without delay, and the resident was transported to Southern California Hospital at Culver City. The resident’s responsible party was notified. Per S2, R1 does not receive one-on-one care. R1 is independent and is residing in the Assisted Living unit of the facility. S1 stated that resident is ambulatory, uses a walker, not a fall risk and does not show signs of being unsteady. LPA Felisa Shirley toured the facility with S2 and went to R1’s room to verify if the pull cord worked. LPA Shirley pulled the pull cord in the bathroom located between the toilet and the shower. Once the cord was pulled, the unit displayed the word, HELP! LPA Shirley then heard on S2’s walkie and the caregiver's walkie in the hallway, that the staff at the front desk received an alert from R1’s room. Upon review of shower list, R1 was not on the shower list as per R1’s physician’s report and Needs and Service plans she is able to dress and groom herself. There is not a Medication Administration Record, (MAR) for R1. Per resident’s physicians report, Needs and Service Plans, Resident Assessment, and Assessment Con'd on 9099-C for Medication Self-Management, R1 was independent and able to administer her own prescription medications. LPA Felisa Shirley spoke with the responsible party and they stated that R1 did not like to be disturbed during the night when she slept. LPA Shirley spoke with and interviewed staff 1 thru staff 10 (S-1 thru S-10). LPA ask, does staff provide adequate care and supervision to residents in care? Of those interviewed, 9 out of 10 answered yes. One staff answered, sometimes. LPA Shirley interviewed residents 2 thru resident 7 (R-2 thru R-7). R1- was not available for interview. LPA ask, does staff provide adequate care and supervision to residents. Of those interviewed, 6 out of 6 answered yes. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 is unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Executive Director Brittany Kavanaugh. There were no deficiencies cited. An exit interview was conducted.