complaint·December 18, 2025

Report, Resident R1's Physician's Orders, Needs and Service Plan, Assessment, and Admission Agreement. The investigation revealed the following: Allegation: Facility Staff did not assist resident with transferring as needed The allegation alleges there is not a sling for the Hoyer lift to transfer residents. During record review, LPA received and reviewed a staff Training Log, dated 04/2025, on the topic of Hoyer Lift Training from PSL Hospice. Additionally, LPA received and reviewed a six (6) page handout on How to Use a Hoyer Lift. LPA received and reviewed an invoice from Omni Care that a sling was ordered on 08/26/2025. During the facility tour, LPA observed a sling for the Hoyer lift, and lifts are operational. Additionally, LPA was shown slings that are available and was informed some residents do not like those slings and do not want them to be used when transferring them. During interviews with Staff S1-S7, were asked if bedridden residents are assisted with transferring from their bed to chair, seven (7) out of seven (7) stated yes, bedridden residents are assisted with transferring from their bed to chair. Additionally, seven (7) out of seven (7) stated the bedridden resident often refuses to transfer from their bed to the chair. Staff S1-S7 were asked if there were any issues with the Hoyer lift, seven (7) out of seven (7) stated no, there have been no issues with the Hoyer lift. Three (3) out of seven (7) stated when one of the residents was transferred to the hospital, the resident’s personal Hoyer sling did not return with them. Additionally, six (6) out of seven (7) staff stated the facility has multiple slings available for use. During interviews with Residents R1-R11, were asked if they are assisted with transferring when needed and wanted, five (5) out of eleven (11) stated yes, they are assisted with transferring when requested. One (1) resident stated, “I don’t trust the slings, so I don’t get up.” Another resident stated they are not going to wait around for them to come, and that they are self-reliant and don’t really need them. Four (4) residents stated they do not require assistance with transferring. Allegation: Facility staff did not assist resident with incontinence care as needed The allegation alleges that a residents incontinent needs are not being met. During record review, LPA received and reviewed Assigned Resident list of residents who requires additional assistance that includes a bed bath, incontinent care, and grooming. LPA reviewed staff training conducted on Relias and observed Caring for Incontinent Residents was completed by staff. During interviews with Staff S1-S7 were asked how often incontinent residents are assisted with changing or checked to see if they need changing, seven (7) out of seven (7) stated they check residents every two (2) hours unless the resident requires more frequent checks. During interviews with Residents R1-R11, were asked if staff assist them with incontinence, seven (7) out of eleven (11) stated staff assist them with incontinence. Two (2) out of eleven (11) stated they do not require assistance with their incontinence but know staff will be there to assist if they need assistance. Two (2) out of eleven (11) stated they do not require assistance with incontinence. Additionally, Residents R1-R11 were asked if they have been left in a soiled diaper or briefs for an extended period of time, seven (7) out of eleven (11) stated they have not been left in soiled diapers for an extended period of time. Allegation: Facility staff did not notify the fire authority within 48 hours of retaining a resident who is bedridden The allegation alleges that the facility is not notifying the local fire department of a resident who is bedridden. During an interview with Staff S1, was asked if notice is sent to the Culver City Fire Department informing them within 48 hours of retaining a resident who is bedridden according to the regulations, S1 stated yes a letter notifying them is sent within 48 hours. During record review, S1 provided LPA with a copy of two (2) letters that were faxed to the Culver City Fire Department dated 04/25/2025 and 09/01/2025 and the fax receipt. LPA observed the letters are updated lists of residents who are on hospice, receive Oxygen, and who are bedridden, and their room number. Staff S1 informed LPA that when the list is updated whether removing a person or adding a person it is sent to the Fire Department. . During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) 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(s) are unsubstantiated . An exit interview was conducted with Business Manager, Maria Garcia, and a copy of this report was provided.