complaint·November 28, 2022

On 03/14/2022 the department received a complaint alleging that: the facility failed to seek timely medical attention based on an observed change of condition in R1. An initial visit was conducted on 3/15/2022 to gather additional documentation, make observations and conduct interviews. In addition IB conducted additional interviews and gathered R1’s medical records. Based on the information obtained during the investigation, it was determined that R1 sustained an injury while be assisted by S1 and S2. Staff sought medical attention within minutes of R1 sustaining an injury. R1 received medical attention at the hospital and received subsequent care at a medical facility. Based on the finding it was determined that the allegations are unfounded. This agency has investigated the complaint alleging facility failed to seek timely medical attention based on an observed change of condition . We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. During the visit on 3/15/22 LPA also observed two staff adjusting R1 in their bed and laying them flat on their back. Nursing notes for R1 state R1 is not to lay flat on their back on the area of their bed sore while they're laying in bed. Home health notes indicate that R1 requires two person assist for bed mobility. Needs and Service plan indicates that the facility will provide assistance when getting in and out of bed and setting up resident for mobility.Therefore, based on interviews conducted, documentation reviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Current Administrator, Yolanda Herrell corrected the deficiency prior to visit by developing a communications logs with assignment sheet and care plans for staff to ensure that all staff are aware of changes in residents care needs. In addition, Administrator developed a ledger for progress notes which allows progress notes to be audited. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given. Exit interview conducted with licensee/administrator. Reports emailed to licensee.