complaint·April 28, 2025

facility maintained a sign up sheet and took attendance for all residents living in the Traditions unit who attended and took part in these activities throughout the day. It was observed that participation was always voluntary but residents were always encouraged to engage as much as they could depending on their physical and mental limits and abilities. It was observed that the lowest number of participants would range from 7-10 participants for any given activity and go up to as high as a 60% participation rate depending on the event and mood of the residents during that time. It was observed that activities were being offered to the residents in the Traditions unit on a daily basis but that the residents still had the right to refuse or participate if they chose to do so. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interview learned that each shift of caregivers, (AM, PM, and NOC), were expected to document and initial the Staff Assignments by Month by Responsible Party at the end of their scheduled shifts. It was also learned that the responsible caregivers for each shift could also initial on this document as the staff assignments were completed throughout their shifts. Based on a review of this document conducted for the month of April 2025, all shifts, (AM-Day, PM-Evening, and NOC-Night), the focus was done just for the staff assignment for the task of Toileting. It was observed that there were several days on the AM-Day shift, as well as, the NOC-Night where initials were missing with no explanation or notations provided at this time. Based on interviews conducted, it was learned that the expectation was that all caregivers were supposed to initial when the staff assignments were completed. It was learned that there should not have been any missing or blank entries throughout all shifts for staff assignments and if there were to be any blank spots then there should have been a circle with an explanation attached. It was observed that these blank spots where staff initials should have been did not have any corresponding documents or information explaining the reason for the blank spots. Based on interviews conducted, it was learned that facility personnel would be considered, and deemed, to not have performed those assigned tasks if they did not properly initial into that day for that particular facility resident. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interview