complaint·December 26, 2023

Continued from LIC 9099 According to an interview with a responsible party (RP), the responsible party stated the facility informed the RP of the incident and immediately assisted the resident. The RP stated the facility corrected the issue and made adjustments to the care plan to ensure the incident with R1 does not happen again. LPA reviewed facility records. According to an incident report submitted by the facility on 09/27/23, R1 had an incident on 09/24/23. Housekeeping staff went to resident's apartment at 10:30 AM and R1 was found on the couch. R1 stated R1 did not feel well and housekeeping called for staff assistance. Resident told staff 3 (3) and staff 4 (S4) that R1 was having back pain and leg pain and had been on the couch since the night before (Saturday night). When Emergency Medical Support staff arrived R1 informed EMS staff that R1 has been on the couch since Friday Night. R1 was treated in the hospital for dehydration and impacted bowel. According to the incident report, Administrator Eric learned from R1's RP that R1 missed Saturday's AM/PM dose of medication. LPA reviewed facility records for R1. According to R1's LIC 602 Physician Report, R1 is considered an independent adult. R1 does not require continued bed care, is able to bathe, dress/groom, feed, and care for own toileting needs, able to administer own prescription medications, and able to store own medications. According R1's Needs and Service Plan, night-time checks utilizing the manual "flipper" door monitoring system is adequate for resident's current needs. Both the LIC 602 and Needs and Service Plan are signed by the RP and Facility Administrator. LPA interviewed staff. According to S1 and S2, R1 reported conflicting information as to when R1 had fallen. One moment R1 stated Saturday evening and the next moment it was reported Friday evening. S2 states that staff are good about checking on the resident's daily. S2 stated that the facility has implemented an extra step to the monitoring system by having staff initial stating they checked on each resident, even those who are considered independent. According to S3, S3 did not see R1 on Friday; however, did see R1's flipper down. S2 stated that the flipper down means that the resident opened their door that day. LPA Valerio reviewed video footage recordings provided by the facility. The facility has security cameras located in common areas of the facility. Continues on Page 3, LIC 9099 - C... Continued from Page 2, LIC 9099 - C Video footage revealed that on 09/22/23 22:45:03 - NOC staff, Staff 4(S4), is seen walking down the hallway. S4 flips up the flipper, which indicates that the flipper was down. On 09/23/23 11:11 AM - AM staff, S3, is seen walking down the hallway. S3 is seen walking up and down the hallway. On 09/23/23 22:29:00 NOC staff, S4, is seen walking down the hallway. S4 is seen going to the door of the resident; however, the camera does not catch whether or not the staff member opened the door or the flip was switched. The staff was in front of the door for less than 10 seconds. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held, and a copy of report was left at the facility.