Allegation: Resident in care sustained multiple falls due to staff neglect/lack of supervision

The details of the complaint alleged that (R#1) sustained multiple falls due to staff neglect and lack of supervision.

On February 4, 2026, at approximately 11:00 AM, during the records review, LPA Iniguez examined a copy of (R#1)’s care plan dated January 20, 2025. The care plan indicates that (R#1) requires full assistance with transfers and mobility, including escorts for meals and activities, wheelchair use, fall risk assessment, and daily observation. The care plan reflects Level 179; the highest level of care provided at the facility. LPA Iniguez also reviewed (R#1)’s Post-Fall Assessment dated December 23, 2025, which is a checklist completed by facility staff after each incident to document and identify the cause of (R#1)’s falls. Additionally, LPA Iniguez reviewed (R#1)’s Medical Assessment (LIC 602A) and observed that it states (R#1) has a medical condition that predisposes them to falls.

On February 4, 2026, at approximately 10:00 AM, during an interview with the Wellness Director (A#1), she stated that a fall-risk assessment and supervision plan is in place for (R#1). (A#1) explained that because (R#1)’s falls are related to seizures, the protocol requires staff to call 911 immediately when an incident occurs. (A#1) further stated that due to (R#1)’s medical condition, the emergency response system is programmed to activate in such situations. Regarding staffing levels and supervision, (A#1) reported that (R#1) receives routine checks every two hours and is on the highest level of care (Level 5). For example, in the morning, staff assist (R#1) with changing their incontinence products and transferring to a wheelchair before escorting them to the dining room for breakfast. After breakfast, staff provide another change and a shower, then escort (R#1) back for lunch, followed by additional changes and assistance throughout the day, including dinner. (A#1) emphasized that (R#1) is supervised by facility staff every two hours and as needed.

Evaluation Report continues LIC 9099-C

On January 29, 2026, at approximately 11:00 AM, during interviews with facility staff members (S#1 through S#5), (5) out of (5) stated that residents identified as high fall-risk are placed on an alert chart, which requires staff to check on them every two hours and as needed. Staff also reported that these residents wear a wristband indicating “fall risk” for easy identification. In addition, when asked what actions are taken after a fall incident, (5) out of (5) facility staff explained that they increase monitoring beyond the standard two-hour checks and inspect the resident’s environment to ensure there are no trip hazards.

Allegation: Staff did not order a new oxygen generator for resident in care in a timely manner

The details of the complaint alleged that facility staff did not order oxygen generator for (R#2) in a timely manner.

On February 4, 2026, at about 11:00 AM, during the records review, LPA Iniguez examined (R#2)’s home health notes binder. The documentation shows the home health agency provides and maintains (R#2)’s oxygen supply and equipment, including the concentrator. The notes describe routine visits and monitoring by the agency. LPA Iniguez found no entries indicating the oxygen concentrator ran out of battery or stopped working. There were no reports of equipment failure, emergency interventions, or communication about oxygen supply issues between the facility and the home health agency.

Evaluation Report continues LIC 9099-C

On February 4, 2026, at approximately 11:30 AM, during interviews with residents in care (R#1–R#10), (10 out of (10) stated that the facility provides their medical equipment and supplies when needed. When asked whether they had ever experienced delays in receiving something important for their health, such as oxygen or other medical equipment, (10) out of (10) residents responded that they had not.

On January 29, 2026, at approximately 11:00 AM, during interviews with facility staff members (S#1 through S#5), (5) out of (5) stated that they have never observed (R#2)’s oxygen machine malfunction or stop working. When asked about the process for checking oxygen equipment and reporting issues such as low battery or malfunction, staff explained that they routinely monitor the equipment during their rounds and would immediately report any concerns to the Wellness Director and contact the home health agency for service. When asked what actions were taken when the oxygen generator stopped working, (5) out of (5) staff reiterated that (R#2)’s machine had never stopped working.

Allegation: Staff engaged in the misuse of the emergency 9-1-1 system

The details of the complaint alleged that facility staff misused the 9-1-1 system to send the (R#1, R#2 and R#3) to the hospital

Evaluation Report continues LIC 9099-C

On February 4, 2026, at approximately 10:00 AM, during an interview with the Wellness Director (A#1), she stated that the facility has a policy in place for contacting emergency services (911). According to (A#1), if a resident experiences a fall or a medical concern, staff first assess the resident, notify the resident's primary care physician (PCP), and notify the responsible party. In most cases, the PCP determines whether the resident should be transported to the hospital via emergency services. When asked about the decision-making criteria and policy used to call 911 for (R#2) (cough/congestion, no acute distress) and (R#3) (equipment issue), (A#1) explained that the facility follows this protocol and acts based on the PCP’s recommendation or the resident’s immediate medical needs. Regarding non-emergent alternatives, (A#1) stated that the facility considers contacting the PCP, using on-call medical professionals, telehealth, same-day clinic visits, urgent care, or arranging non-emergency transportation to the hospital. However, if the resident requires immediate medical attention or the PCP advises emergency transport, the facility will utilize the 911 system. (A#1) emphasized that these decisions are made to ensure resident safety and timely access to care.

Evaluation Report continues LIC 9099-C

On January 29, 2026, at approximately 11:00 AM, during interviews with facility staff members (S#1 through S#5), (5) out of (5) stated that when a resident requires medical assistance, they inform the MedTech on duty. Staff explained that before calling 9-1-1, the facility’s process includes notifying the Wellness Director, who assesses the resident’s condition and contacts the resident’s primary care physician (PCP) to determine the next steps. In addition, (5) out of (5) staff indicated that the decision to call 9-1-1 is based on the assessment and PCP recommendation, and emergency services are used only when immediate medical attention is necessary.

During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the Complaint Report was given to Joe Saldana/Executive Director.