complaint·December 2, 2024

During an interview with Resident #1, LPA learned that during one incident, staff was assisting the resident out of bed when the resident slipped and fell on the guardrails. During this incident, Resident #1 could not identify the date, time and/or the staff members involved with the assistance. A review of an incident report dated for September 17, 2024, reflected that the resident fell and that the Responsible Party was notified of this fall. In addition, LPA reviewed an additional incident report dated for September 20, 2024, which reflected the residents change of condition. Furthermore, LPA could not corroborate the allegations. Complaint alleges that Staff did not ensure resident was fed. Based on observation of facility records, resident records and interviews that were conducted, LPA received inconsistent statements. Furthermore, during an interview with Resident #1, LPA learned that the resident would eat three times a day and would order food, and that staff would drop it off in the room. During a review of the Progress Notes on October 24, 2024, LPA observed in the notes that the resident had to be reminded to eat food. Furthermore, LPA could not corroborate the allegation. Complaint alleges that Staff mismanaged resident's medications. Based on observation of facility records, resident records and interviews that were conducted, LPA received inconsistent statements. Furthermore, during a collateral interview with Resident #1, LPA received inconsistent statements as it relates to the amount that was given. During the opening of the complaint on October 4, 2024, LPA reviewed the Medication Administration Record (MAR) and the Medication Order for the medication in question, LPA did not observe any discrepancies. Furthermore, LPA could not corroborate the allegation. Complaint alleges that Staff did not answer resident's call button in a timely manner. Based on observation of facility records and interviews that were conducted, LPA received inconsistent statements. Furthermore, during a review of the call button history, LPA observed no calls exceeding one hour as initially reported. LPA could not corroborate the allegation. Complaint alleges that Staff did not ensure resident's room was cleaned and sanitized. Based on observation of facility records and interviews that were conducted, LPA received inconsistent statements. Furthermore, during a collateral interview with Resident #1, Resident reported that the staff members cleaned the room. LPA could not corroborate the allegation. (Report continued on LIC 9099C Complaint alleges that Staff are not properly trained to transfer residents. Based on observation of facility records, LPA received inconsistent statements. Furthermore, during a review of staff training records on December 02, 2024, LPA observed sufficient training hours as outlined in Title 22 Regulations. LPA could not corroborate the allegation. A finding that the complaint allegations of Staff caused injuries to resident in care, Staff did not ensure resident was fed, Staff mismanaged resident's medications, Staff did not answer resident's call button in a timely manner, Staff did not ensure resident's room was cleaned and sanitized, Staff are not properly trained to transfer residents and Staff did not report incidents to resident's responsible party are unsubstantiated meaning that although the allegations 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 allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.