complaint·February 10, 2023

It was also alleged facility staff left resident in soiled bedding for an extended period of time. Investigation revealed resident R1 was not able to get assistance at night. It was corroborated, staff respond during the day, when residents call for assistance, but when the bell is used at night, staff cannot hear and do not respond. In addition R1 did not have a bell. It was disclosed to LPA resident R1, called for assistance to use the bathroom/potty chair and staff did not respond. R1's physician report states R1 needs assistance out of bed as they are at fall risk. R1 stated they slipped to the floor, urinated and then grabbed blanket to cover themselves as it was cold and remained on the floor in a soiled floor/blanket until the morning when staff found R1. There was no indication of the exact time R1 was left without assistance as they were not able to communicate with staff. LPA received contradicting statements from staff who stated, R1 was found hiding on the floor, was not urinated but had heard/seen R1 throwing up. Staff later disclosed, they found R1 with throw up sitting on the floor at 4 am. Staff also stated R1 was not there long and had probably just threw up, yet staff disclosed to LPA they last saw R1 at 1am and then saw R1 again around 4am. Based on LPA’s record review, statements received, and contradicting statements from staff, the preponderance of evidence standard has been met, therefore, allegations for, "facility does not have not have a proper system for residents to alert staff for assistance and facility staff left resident in soiled bedding for an extended period of time; are both 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.