complaint·February 4, 2025

In regards to the allegation: "Staff left residents in soiled depends for a long period of time." It is alleged that staff observed multiple residents left in their feces and urine for a few hours last week. (4) out of (5) staff interviewed denied the allegation and stated that they have adequate staffing at this time. S1 stated that they do staffing based on acuity and there are 4-5 staff assigned per shift. Staff stated that they conduct rounds every 2 hours per shift or as needed, not only to change undergarments for incontinent residents, but to check if residents are doing well or need other assistance. Interviewed residents denied the allegation. (5) incontinent residents who were interviewed stated that staff assist them all the time in toileting, changing and never left them in soiled undergarments. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of residents' files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations 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. Exit interview conducted and a copy of this report was provided to Andrea Barraza, Memory Support Director. The investigation revealed the following: In regards to the allegation: "Staff did not prevent residents from sustaining multiple falls." It is alleged that most of the residents are falling out of their beds and staff are not doing anything to prevent the falls. And recently, a resident who is a fall risk, fell when getting out of bed. 4 out of 5 staff interviewed denied the allegation and stated they have adequate staffing. Staff interviewed stated that they have completed training regarding fall risk, dementia care and documentation. S1 stated that majority of the residents do not have one-on-one care. S1 stated that the facility has a fall reduction program and staff are aware of the protocol to prevent residents from falling. Interviewed staff indicated that they use different intervention techniques to prevent them from falling like providing fall mats, bed rails for hospice residents, do strength and balance exercises to improve their balance, encouraging residents to stay in the common areas, and/or attend activities for extra supervision. Interviews with residents stated that staff do all the best they can to prevent the residents from falling. Some interviewed residents who experienced a fall stated that the staff conducted body checks, assessed and provided first aid on them. Interviewed residents stated that staff are supportive and conduct routine checks daily. LPA observed enough staff members working and assisting residents during the visit. Therefore there was insufficient evidence to corroborate with this allegation. In regards to the allegation: "Staff did not prevent residents from sustaining injuries while in care." It is alleged that there have been multiple falls at the facility and residents have sustained black eyes and “busted faces” due to these falls. Additionally, a resident fell and hit her face on the night stand, resulting in a cut on her face close to her eyebrow. Interviewed staff denied the allegation. S1 stated that she was aware that R2 who is receiving hospice care experienced an unwitnessed fall and when it occurred, R2 was promptly attended to, evaluated and underwent a body check by the staff. S1 stated that R2 did not have a one-on-one care and that R2 had a minor cut above her eyebrow, but there was no apparent trauma. Nonetheless, 911 was called to assess R2 and the paramedics suggested transporting R2 to the hospital. R2 was not hospitalized and did not sustain major injury. Interviewed staff indicated that they use different intervention techniques to prevent residents from falling and sustaining injuries like providing fall mats, bed rails for hospice residents and encouraging residents to stay in the common areas, and/or attend activities for extra set of eyes. Interviews with residents stated that staff do all the best they can to prevent residents from sustaining injuries. Interviewed residents stated that staff assist them with their needs and monitors them regularly. LPA observed enough staff members working and assisting residents during the visit. Therefore there was insufficient evidence to corroborate with this allegation.