Complaint·January 22, 2025

On 10/14/24 the Department visited the facility and observed R1, who was present watching TV. R1 was well groomed and not exhibiting any signs of distress or discomfort. LPA Ramirez made multiple attempts to speak with R1, however they were unable to effectively communicate with LPA. The Department was able to inspect R1’s records which revealed that there were no relevant diagnosis or medical need for the use of restraints or postural supports. Records also revealed contact information for R1’s family member and responsible party (OS4). The Department attempted to contact OS4 several times however voicemails were not returned. On 10/14/2024, LPA toured the facility which included an inspection of wheelchairs, bedrooms, and common areas. There was no evidence of restraints, however one beige gait belt was observed sitting on the seat of a wheelchair in the living room, loose and unattached. Shortly after, LPA observed a staff member use the belt to assist a Resident (R3) in transferring from the couch to their wheelchair, and then to their room. At no point during the transfer was the belt fastened or secured to R3 or their wheelchair. LPA later inspected R3’s room, where a medical professional (OS6) was inside tending to R3. OS6 reported that they visited the facility frequently and never observed the use of restraints, or did they observe improper use of Gait belts, which they reported are commonly used in care facilities to safely assist Residents who need help with mobility and transfers. Of the four remaining Residents (R2, R3, R4, R5), LPA was only able to successfully communicate with R2, who used body gestures and limited language to respond. According to R2, no Residents had straps or belts on them when seated in wheelchairs. Additionally, LPA spoke to the facility administrator and one staff member (S1, S2), and both denied the allegation. On 11/18/24, LPA conducted additional interviews with outside sources (OS1, OS2). OS1 was a responsible party for a resident. OS1 stated that they were present in the facility several times during the period of the allegation, had no concerns and denied ever witnessing residents strapped to wheelchairs at the facility. OS2 was a family member of an additional Resident and stated that they were present in the facility weekly during the time of the allegation. According to OS2, residents had never been strapped to their wheelchair and they had no concerns about care & supervision. (See LIC 9099C for continuation of report.) While two staff members (S1, S2), one resident (R2), two family members (OS1, OS2) and one medical professional (OS6) denied the allegation, an outside source (OS5) was able to corroborate the allegation on 11/18/24 by providing photographic evidence. Photographic evidence showed R1 seated in a wheelchair with a belt strapped across their abdomen and around their wheelchair seat. The belt was identical to the belt previously observed by the LPA in the facility on 10/14/24. In the photo, the belt was latched behind the wheelchair and out of reach of R1, which prevented them from releasing the clasp. On 12/6/24, LPA visited the facility and confirmed the person in photograph’s provided by OS5, was R1. LPA asked permission to take resident/victim’s photo, after which the resident nodded their head yes in approval. LPA inspected the environment and further noted that flooring and walls from photographs provided by OS5, matched those of facility. A further review of the facility file confirmed that there were no documented exceptions on file for the use of postural supports, which when approved, may only be fastened or tied in a manner that permits quick release by the resident. The departments review of the available evidence revealed that the preponderance of evidence standard was met and the allegation was SUBSTANTIATED. A deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A plan of corrections was developed with Administrator. An exit interview was conducted with Administrator to whom a copy of this report and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.