Complaint·January 10, 2023

Through documents provided to LPA by the Licensee, LPA found that the last training done on catheter care was on June 9, 2022. LPA reviewed the training for the caregivers on the day of the incident (December 28, 2022) and found that during the incident, Caregivers Erniwati Keeling and Melvenia Vega had the most recent catheter training and were 2/3 caregivers on the schedule for their shift. Julio Ramirez-Mercado (3/3 caregivers) did not have the training. Caregiver Ramirez-Mercado was hired July 21, 2022 after the last catheter care was conducted. LPA reviewed Ramirez-Mercado's training that was conducted, and found no catheter care documented. Upon interview, Ramirez-Mercado further stated that they had no official catheter care training. Thus, this allegation was SUBSTANTIATED. Regarding the allegation, "Staff inappropriately restrained a resident while in care." It was alleged that staff restrained R1 to their bed utilizing their bed sheets. LPA interviewed R1, Memory Care Resident Services Director Emerald Mobley, Caregiver Melvina Vega, and Caregiver Ramirez-Mercado. Through interviews conducted, LPA found that R1 had been restrained to their bed utilizing their sheets. Caregiver Ramirez-Mercado stated that they felt that R1 would cause injury to themselves and needed to be restrained. Thus, this allegation was SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. LPA issued (2) citations per Title 22 in reference to the allegations. An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811 (Confidential-Names List), LIC9099-D, LIC9099-C, and Appeal Rights were provided.