Complaint·February 6, 2023

1) Resident’s legs are pointed inwards, and the NOC shift caregiver who was assigned to the resident “was not paying attention” to the direction of the resident’s legs and moved it the wrong way when it was time to change the resident’s diaper. 2) The resident moved her legs the wrong way on her own and her leg may have gotten leg stuck between the wall and bed. The NOC shift caregiver who was assigned to resident may have observed the injury upon changing resident’s diaper, however, failed to report the incident and observation made to a supervisor. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. For today’s visit, deficiencies were issued per Title 22, California Code of Regulations. LPA De Perio conducted an exit interview with Facility Administrator, Sarah John, and a copy of this report was provided to the facility.