Complaint·October 3, 2024

A resident sustained multiple falls due to neglect and lack of super vision. On 9/26/2024, LPA conducted a phone interview with R1s responsible party (RP) and RP stated that R1 does scoot off the bed, tries to get up and thinks that he/she can walk. R1 shakes due to R1s condition. On 9/28/24, from 9:00 a.m. to 12:00 noon, LPA conducted an interview with 4 staff (S1 to S4). 3 Out of 4 staff states that resident (R1) is non-ambulatory, but always tries to get up or scoots off the bed or slides of the wheelchair. 1 out of 4 helps prop R1, when R1 starts to slides of the wheelchair, but did not see R1 fall of a wheelchair. 3 out of 4 stated that R1 is getting checked every two hours, because of R1s history with fall and wanting to get up, staff increased their supervision by checking on R1 every hour. 3 out of 4 staff stated that after 5 or 15 minutes of being checked R1 will be on the floor again. Residents are not accorded with dignity and respect. Based on interview of 4 staff. 4 Out of 4 staff stated that they always respect the resident's personal rights. If they refuse they cannot force the resident. They are free to do what they want and staff supervise or redirect residents. 4 out of 4 stated they care for the resident and they try their best to keep residents active and happy. 4 out of 4 stated they have not seen or witness a resident not accorded with dignity and respect. Staff are being rough when providing assistance with residents' care. Based on interview with 4 staff. 3 Out of 4 staff stated, that there was a caregiver before, who got terminated because of abuse that was a year or more ago, and it's been investigated by the Ombudsman. 4 out of 4 stated they have not seen or witnessed a caregiver be rough with the resident after the incident from last year. Based on document review and interviews, R1 has a condition that contributes to his/her fall due to mental and physical condition and is being addressed on their appraisal needs and services plan. 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, therefore the allegation is unsubstantiated. No deficiencies are cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with ED/ADM Holly Suiter and a copy of the report was provided.