complaint·June 5, 2024

Staff stated that R1 was admitted to the facility on January 10, 2024, and stayed for nine days. Staff stated that on or about January 12, 2024, R1, called with a notification bell at approximately 7:15 a.m. Staff found R1 sitting in bed and required changing and toileting. R1 attempted to use their standing pole to transfer from bed to wheelchair, but R1 lost their balance. Staff could not support R1’s weight and advised R1 to slide slowly to the floor. R1 requested Staff call 911. Staff determined it was not necessary as R1 had no bruises or bumps and did not complain of any pain. R1 only required to be cleaned up and lifted off floor. Staff cleaned up R1 and provided R1 with a blanket and pillow. After cleaning up R1, Staff called for assistance from another caregiver at 7:45 a.m. R1 was moved into wheelchair by 8:10 a.m. R1 stated that they were okay and had no complaints of injury. There was no evidence of any injury to R1. Administrators and staff collectively dispute that R1 fell from their bed on January 12, 2024 or that R1 was on the floor for an inordinate amount of time after sliding on to floor. On January 14, 2024, a law enforcement officer conducted a welfare check on R1. Staff stated that R1 told the officer they were fine. A police report was not filed, and the officer did not leave a business card. Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. On the allegation: Staff did not provide medical attention/physical therapy as needed to resident in care. It was alleged that R1 was not receiving necessary physical therapy. Staff stated that Mission Home Health of Central Coast visited the facility and provided R1 with physical therapy on two occasions. In addition, a nurse visited twice to assist with R1 wound care. R1 only resided in the facility for a total of nine days. Staff claimed that the physical therapist advised that R1’s knee was too swollen to perform exercise. Physical therapist advised staff to ensure that R1 perform 5 repetitions of sitting to standing from wheelchair each morning. Staff advised there is no written documentation of these instructions at the facility. Witness 2 (W2) confirmed that a nurse conducted an initial visit of R1 on January 13, 2024, and performed a subsequent visit on January 18, 2024. A physical therapist and occupational therapist conducted evaluations on January 14, 2024, and January 15, 2024, respectively. (Cont. 9099-C) W2 stated that there is no evidence of an exercise plan because R1 was hospitalized effective January 19, 2024. W2 further stated that clinicians were concerned that R1 required a higher level of care. R1 was ultimately moved into a skilled nursing facility. W2 advised that before admissions into facility, R1 was recovering from a left hip fracture that was surgically repaired. Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted, copy of report issued.