Complaint·October 18, 2024

Regarding the allegation of Facility staff left resident on the floor for an extended period of time after falling, RP stated that a resident (R2) fell from the bed on either 3/4/2023-3/5/2023 during NOC shift and was left on the floor more than 1 hour. Based on records review, an incident report was submitted by the Licensee. R1 was sent to hospital after it was found out that R1 had an unwitnessed fall. Licensee has already addressed the issue with the staff. Regarding the allegation of facility does not have adequate staffing, RP stated that a staff member (S2) let RP know that they are always short staffed especially on the weekends. LPA interviewed the Licensee (L1), and it was stated that for staffing, 3 in the morning, 3 in the afternoon, 3 NOC shift. If it is short staffed, the manger stops managerial work and steps in to help. L1 and L2 will also help, be on the floor, serve meals, clean up. When someone calls off, we have a list of people that are on call or not scheduled that we can ask to come in. Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. Based on records review, Licensee was able to provide proof of training from Relias for S1. The following topics were used for Medication training: Actions and Interactions of Common Medications; Assisting with Self-Administration of Medications: Guideline, Medication Orders, Procedure, The Basics; Medication Documentation for California; Providing Medication Assistance – California, Psychotropic Medications: Antipsychotics and Beyond. All trainings were finished through online completion on 2/5/2022. Based on interviews and records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. page 2 of 2