complaint·May 18, 2021

At about 12:10am on 10/3, staff showed up thinking R1 had pulled his call button in the living room, but R1 was not in the living room, R1 was in his room. Staff commented that there was no way he could have pulled that button. At about 12:23am, R1 disclosed to staff he was shaking really bad; as staff left, they stated to R1, “you might have something else going on”. R1's family also disclosed R1 informed staff he was cold and facility staff expressed to R1 that he had four blankets, it was 75 degrees and his room was warm enough. It was also disclosed by family, R1 was heard crying as staff left his unit. Review of the resident appraisal that was documented by facility, R1 did not need special observation due to confusion or forgetfulness. Facility staff failed to observe, document and meet the needs of the resident when he expressed confusion between day and night and expressed to facility to be cold, shivering while at a warm temperature and using 4 blankets. R1 was later seen at around 8am, when facility staff found R1 on the floor next to his bed and staff stated he had rolled out and were unsure how long R1 was on the floor. Although R1 did sustain a fall, it was reported R1 was not a fall risk and there is no supporting documentation to verify if the fall could have been prevented. Hospice agency and family was said to have been notified of the fall and the resident was sent to the hospital where he was later diagnosed with a UTI. R1's family disclosed there were several times R1 would be pushing the call button because he needed assistance and no one would answer the call or it would take a long time for response. Investigation revealed, the facility staff were taking up to 32 minutes to respond to R1’s call button and in many instances, it was taking staff up to 20 minutes to respond. A statement from staff also corroborated the call button not working properly or identifying which call button was pressed in the room. R1’s family also disclosed in some occasions, when they were there at the facility, and pushed the call button themselves, no one responded, and the call button was not operational, this was brought up with the facility. Facility staff S1 acknowledged there were times where the response time was way longer than what the facility tries to do and states the call button was operational. Based upon statements made and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal of rights provided