Complaint·July 1, 2025

Continued from 9099.... 6 taking 15 to 44 minutes and three calls taking from 1.56 hours to 3 + hours therefore the allegation is substantiated. (See 809D for the deficiency cited). The complaint alleges Staff do not follow the resident’s care plan. The complainant states some residents’ care plans state they need 2-person assistance due to needing a Hoyer lift, or for incontinence care, and staff have been told to do it on their own. The complainant stated resident R2 is a fall risk, and management said they need to be watched one on one. The complainant stated that it wasn’t communicated to all staff, and R2 fell out of bed 2/13/25. LPA spoke with staff S1 who reported that R2 had enhanced care services 1:1 between 1/22/2025 until 5/13/2025, which were clearly listed in the care plan which is completed by care staff members. The care records for R2 show they had enhanced care services and were receiving additional supports including escorts to and from activities and meals, mealtime support, hourly checks. According to S1, on 2/13/2025 R2 didn't fall but slid out of bed; there were no injuries (the facility utilizes Safely You camera). LPA conducted interviews and found that 6 out of 6 staff stated the company policy for care staff who are providing care independently must ask for assistance from another staff member when providing care for a Hoyer lift or a 2-person assist. Zero of 6 staff stated that they were instructed to initiate care alone for a two person assist. However, 2 of 6 staff members interviewed stated that if they did not receive a timely response to their request for assistance the staff member would aid the resident alone, despite the company policy. Therefore, the allegation that staff do not follow the care plan is substantiated. (See 809D for the deficiency cited). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Continued on 9099-A Continued from 9099-A Medication list does show barrier cream to be applied once per day but makes no reference to any redness or other concerns. Therefore the allegation that Staff do not ensure that resident is repositioned is unsubstantiated. The complaint alleges Staff do not prevent residents from engaging in inappropriate behavior. The reporting party stated 2 residents (R3 and R4) were found in bed together. Based on interviews LPA found that staff did not anticipate the behavior of residents R3 and R4. During a group activity staff noticed R3 and R4 missing from an activity and when they went to check on them R3 and R4 were found together in bed; an activity within their personal rights. There was no incident report filed citing any abuse or misconduct, and responsible parties were notified. Although it may have been unanticipated residents were exercising their personal rights - not engaging in inappropriate behavior, therefore the allegation that Staff do not prevent residents from engaging in inappropriate behavior is unsubstantiated.