Complaint·January 27, 2023

As part of the reporting requirement, the facility reported it to R1's physician , Long Term Care Ombudsman and R1's responsible party; subsequently, R1 was seen by R1's physician on the following day. The facility also attempted to collect more details from staff, but none of them had knowledge of such incident as it was witnessed. As prevention, facility offered R1 to move to another room on a different floor but R1 did not accept the offer. However, the facility was able to move R2 after a discussion with the responsible party. Since the room transfer, there was no further incidences. Based on the documents provided by the facility, LPA observed this incident was reported on 11/20/2020 (incident happened on 11/19/2020) via LIC 624 (Unusual Incident/Injury Report) indicating that it was reported to R1's responsible party, Long Term Care Ombudsman and R1 was seen by On-Lok Clinic. In addition, a SOC 341 ( Report of Suspected Dependent Adult/Elder Abuse) was also completed. Based on interviews, and record reviews during the course of the investigation, this allegation is deemed to be unsubstantiated. Regarding to allegation of- facility staff are not meeting toileting needs of resident and facility lacks adequate staffing to meet resident's care needs, there is not additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that facility staff failed to change R1's soiled diaper and asked R1 to poop in R1's diaper. As part of the investigation, LPA interviewed R1 who stated that it took the staff hours to change R1's soiled diaper. The administrator and the resident care coordinator denied the above allegation and stated that every morning before night shift staff ends their shift at 6:30am, they would clean, change, provide a bed bath and get R1 into a wheelchair to start R1's day. In addition, they have not heard any complaints from R1, the responsible party and the physician regarding this allegation. Furthermore, the administrator stated that the facility recently added additional staff to anticipate new residents from Laguna Honda. LPA interviewed staff #1 (S1) who stated that night shift staff would clean, change and get R1 ready for the day and when S1 arrived at work, R1 was already cleaned and up in a wheelchair. S1 was not aware of such allegation. In addition, S1 stated that staff assisted R1 to the toilet during the day and R1 performed self-care after toileting unless R1 requested for assistance. LPA interviewed 3 other residents regarding to the care that they received by staff including but not limiting to toileting needs and all of them reported that they were satisfied with the care that they received and staff was attentive to their needs. During the initial visit, LPA observed residents to be cleaned, comfortable and LPA did not smell any unpleasant odor at the facility. Based on observation and interviews during the course of the investigation, this allegation is deemed to be unsubstantiated. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. LPA observed R1's medication administration record that indicated this specific medication was ordered for 5 days and 4x daily and the medication administration record indicated that it was properly administered by facility staff. Based on record review, and interviews during the course of the investigation, this allegation is deemed to be unfounded. Regrading to allegation of facility staff are retaliating against the resident for filing a complaint- there is no additional information forthcoming from the reporting party and R1. As part of the investigation, LPA interviewed the administrator who denied the allegation and stated that facility encouraged residents and their responsible parties to contact the advocates such as the Long Term Care Ombudsman and the Long Term Care Ombudsman information is posted in the facility. Therefore, this allegation is deemed to be unfounded as there is no details provided. . Regarding to staff did not prevent another resident from entering resident's room- there is no additional information forthcoming from the reporting party. The administrator denied the allegation and stated that this incident was not witnessed by facility staff and if it was, staff would have discouraged R2 from entering R1's room. LPA interviewed R1 who stated that when R2 followed R1 into R1's room, there was no staff around to stop R2 from doing that. Based on interviews during the course of the investigation, this allegation is deemed to be unfounded. Regarding to allegation of- staff does not treat resident with respect, there is no additional information forthcoming from the reporting party. As part of the investigation, LPA interviewed other residents who stated that facility staff is attentive, they treat residents with respect and dignity. Based on interviews during the course of the investigation, this allegation is deemed to be unfounded. Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.