complaint·March 10, 2022

2. LPA Hiratsuka, interviewed residents and staff on 10/13/2021, and 10/27/2021. LPA also interviewed former caregiver, Complainant, and a couple of witnesses. LPA reviewed facility records for residents. Residents and one witness interviewed stated they have no issues with staff. LPA was informed staff are repeated told to watch what they are doing when transporting residents because the hallways have just enough space to maneuver someone who is in a wheelchair in and out of the hallways. Caregivers and one resident stated that caregivers have bumped the resident into the wall while trying to get the resident in the hallway to their room, but there were no injuries, the caregiver that was moving the resident very slowly, was being very careful and talking the resident through the maneuver, it was not intentional, and it doesn’t happen often. Complainant stated residents had bruises on their arms and legs caused by the rough manner. A witness stated they saw caregivers banging a former resident into stuff. LPA was unable to interview the former resident. A former caregiver denied banging residents into stuff. LPA did not observe any bruises. Because there are several versions of events, LPA cannot prove or disprove the allegation. Allegation unsubstantiated. 3. LPA Hiratsuka, reviewed the resident in question’s file, interviewed the one of the caregivers on duty and a former caregiver who was on duty, and unable to interview the resident who moved out due to their injuries. The facility incident report stated the resident was observed earlier in the day attempting to get up without assistance and one caregiver was walking by and was able to assist the resident from getting up and then a short time later the caregivers on duty heard a sound come from the resident’s room and found the resident on the floor. The facility records and interviews all state the resident did not have a history of getting out of bed without assistance and would wait for someone to show up to assist after pressing the call button. The caregiver who stopped to assist the resident stated that was the first time the resident was observed attempting to get up without calling for help. The former caregiver stated they had just left the resident’s room after visiting with the resident and was walking to another resident’s room when they heard a sound and found the resident in question on the floor with severe injuries. Caregivers called 911 and the resident was taken to the hospital and did not return due to requiring higher level of care. All caregivers interviewed stated all residents are fall risks and they do frequent checks on residents. They stated there is one caregiver constantly walking around checking on residents. Title 22 regulations does not require residents to be with caregivers all the time. The regulations require a written plan of care that tells caregivers what residents require assistance with and approximately how often a resident should be checked on. The regulations require the facility to update the plans of care when there is a change in condition or every 12 months; whichever comes first. There are times where a resident requires one-on-one supervision and when that happens the facility may provide the caregiver, or the family may provide the caregiver and there’s a written agreement addressing the issue. LPA cannot prove or disprove the resident fell because of lack of supervision. Allegation unsubstantiated. House Manager was informed to refuse to sign report by Licensee. 4. LPA Hiratsuka, interviewed the one of the caregivers on duty and a former caregiver who was on duty and residents. LPA was informed a former caregiver was not changing residents during the NOC shift and left residents soiled in the morning. LPA contacted the former caregiver and the former caregiver denied not changing residents. The former caregiver stated they changed the residents who required it during the late night/early morning hours and made sure everyone was changed at least once before the shift ended. The former caregiver stated they did not leave anyone soiled. Complainant and witness stated there was at least one instance of the former caregiver leaving residents soiled. LPA interviewed the residents and found no complaints. LPA cannot prove or disprove the allegation. Allegation unsubstantiated . “This agency has investigated the complaint alleging; Resident(s) are not being provided clean bedding; Resident(s) room is malodorous; and Resident(s) room is unsanitary.. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis." House Manager was informed to refuse to sign report by Licensee.