complaint·January 28, 2025

The investigation revealed the following. Regarding Allegation(s): Resident developed pressure injuries in care - It is alleged R1 developed pressure injuries while receiving care at the facility. Two (2) out of the two (2) staff interviewed denied this allegation. Three (3) out of the four (4) residents interviewed denied this allegation. Interview with R1’s responsible party denied this allegation. Physicians report (LIC 602A) dated 1/15/2025, revealed R1’s physician observed R1’s skin integrity to be normal and clear. R1’s physician did not observe bedsores or abrasions. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Facility staff are not repositioning the resident as needed - It is alleged that staff are not repositioning R1 as needed. Two (2) out of the two (2) staff interviewed denied this allegation. Three (3) out of the four (4) residents interviewed denied this allegation. Interview with R1’s responsible party denied this allegation. LPA Ramirez reviewed R1’s resident records including R1’s physician orders. LPA Ramirez did not observe a physician’s order indicating staff shall reposition R1. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Facility staff are not meeting incontinence care needs of resident- It is alleged staff leave R1 soiled. Two (2) out of the two (2) staff interviewed denied this allegation. Three (3) out of the four (4) residents interviewed denied this allegation. Interview with R1’s responsible party denied this allegation. During facility tour, LPA Ramirez observed six (6) out of the six (6) residents to be well groomed and residents’ rooms were not observed to be malodorous. LPA Ramirez observed all resident beds to contain disposable incontinence pads and required linens. LPA Ramirez observed the facility to have sufficient supply of incontinence care products. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Facility staff speak inappropriately to resident – It is alleged staff spoke inappropriately to R1. Two (2) out of the two (2) staff interviewed denied this allegation. Three (3) out of the four (4) residents interviewed denied this allegation. Interview with R1’s responsible party denied this allegation. During tour of facility, LPA Ramirez observed staff providing care and supervision. LPA Ramirez observed staff to be professional and did not observe staff speaking inappropriately to residents. Staff interviewed were knowledgeable on residents’ rights and on specific needs of the residents’ they serve. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited during this investigation. Exit interview conducted. A copy of this report was provided.