complaint·January 9, 2024

The investigation revealed the following: In regards to the allegation of: resident sustained an injury from a fall while in care, it was alleged that the resident fell and injured when getting up from resident’s own wheelchair at the facility. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. One (1) out of eight (8) residents was deceased and unable to be interviewed. Resident interviews revealed that they did not fall from their wheelchair or staff would assist them right away when they fell. All staff interviewed denied the allegation. Per staff interviews, staff stated the resident got agitated and fell off from resident’s own wheelchair when resident tried to get up by oneself. Per record reviews, it indicated that staff was trained to provide care to resident who had fall risk. Staff assisted resident and provided care after the fall occurred. Resident had plan of care in place. Thus, there was not preponderance of evidence to show resident sustained an injury from a fall due to lack of care. In regards to the allegation of: staff did not address a resident's diabetic needs while in care, it was alleged that staff failed to check resident's glucose by using Glucose meter. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff provided residents with diabetic medication and had the LVNs or their own health care nurses monitored their glucose level. Meals were modified per doctors' prescription for diabetic residents. All staff interviewed denied the allegation. Per staff interviews, staff stated only LVNs allowed to administer glucose check using glucose meter. Other staff were not qualified to administer residents’ glucose tests. Per record reviews, resident was on hospice care. No doctor prescription to order blood test on resident. As a result, there was not preponderance of evidence to show staff failed to address diabetic needs. In regards to the allegation of: staff are using a resident's room for work breaks, it was alleged that staff used resident’s room as a break room. Seven (7) out of eight (8) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff did not use their room as staff's break room. All staff interviewed denied the allegation. Per staff interviews, staff stated they had their staff break room and did not need to use resident’s room for taking breaks. Per observation, staff took breaks in their staff break room. Therefore, staff did not use resident's room for work breaks. (-continued in LIC 9099 C-) 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. No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator. A hard copy of this reports were provided.