The Department interviewed facility staff, residents, and record reviews. During the investigation, it was determined that there was insufficient evidence to substantiate neglect/Lack of care and supervision resulting in an unwitnessed fall. On 12-26-2021 Resident 1 (R1) sustained an unwitnessed fall in her bedroom. R1 was interviewed and was unsure of the amount of time she was on the ground, but stated it was only a few minutes. R1 stated that staff assisted her back in bed after the fall. R1 was unsure if the staff conducted and evaluation of her. R1 refused to go to the hospital and can handle all her ADLs. Per R1’s care plan she needs stand by assistance only, not a fall risk and able to ambulate on her own. Per staff R1 is one of the facilities most independent client.

Staff did not notify resident's responsible party of a change in resident's condition.

The Department interviewed facility staff, residents, and record reviews. During the investigation, it was determined that there was insufficient evidence to substantiate staff did not notify resident's responsible party of a change in resident's condition. The facility staff and clients all verbally reported to LPA that they have never had any issues with the facility not informing the responsible party of any change of conditions. Interviews with staff all indicate that they note any changes and report them to the Administrator, who then notifies responsible party.

Resident was left in soiled clothing for a long period of time

The Department interviewed facility staff, residents, and record reviews. During the investigation, it was determined that there was insufficient evidence to substantiate Resident was left in soiled clothing for a long period of time. Facility staff and residents all verbally reported to LPA that they have never been left in soiled or poopy clothing for long period of time. All residents reported that they are checked on every two (2) hours and have never had any issues.

The Department interviewed facility staff, residents, and record reviews. During the investigation, it was determined that there was insufficient evidence to substantiate Staff did not administer medications in a timely manner. LPA reviewed 3 out of 3 residents Medication Administration Records (MARS), Medications and conducted interviews. LPA reviewed staff schedules and determined that only Med Techs have access to the Medication Room. The medications are stored in a medication cart that is locked in the medication room and only the Med tech has the keys. Interviews with staff revealed that med techs were giving medications at the appropriate times and residents did not miss any medications. Residents that were interviewed indicated that to their knowledge they were getting their medications in a timely manner and one resident reported that “There is no problem with me getting my medications” and that “Staff take really good care of us.” In addition, a review of the MARs document was conducted, and it did not reflect residents not getting their medications, as required.

The Department interviewed facility staff, residents, and record reviews. During the investigation, it was determined that there was insufficient evidence to substantiate Residents are not provided activities. During the month of December 2020, it was reported that activities were not being provided. Due to the state restrictions in place for the reason of the Covid Virus. It was reported that staff and residents have been vaccinated for the Covid Virus, restrictions have been lifted; therefore, activities have resumed daily. Activities provided include review of, Bingo, arts and crafts, exercise, food activities, movies and snacks, and coffee chats. It was also reported by staff and residents that some residents “choose” not to participate in daily activities. Residents have personal rights to choose if they want to participate in activities or not.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred

The Department interviewed facility staff, residents, and record reviews. During the investigation, it was determined that there was sufficient evidence to substantiate Staff did not seek medical attention in a timely manner. On 12/26/2020 R1 sustained an unwitnessed fall. Per facility policy, any unwitnessed fall with complaints of pain is an immediate 911 send out. According to facility staff R1 did have complaints of pain to her back after her fall. R1 was evaluated per facility policy. R1 denied wanting to go to the hospital. Staff stated that they “cannot force a client to go to the hospital if they don’t want to go”. R1 continued to have complaints of pain the following days after her fall. Staff reported that they asked R1 everyday if she wanted to go to the hospital, but again she denied wanting to go. R1 was eventually taken to the hospital on 12/30/2020. According to Fairchild Medical Center, R1 sustained a rib fracture to her right side. The facility failed to follow their own policy regarding unwitnessed falls, therefore the allegation of failure to seek timely medical attention in substantiated.

Facility is in disrepair.

The Department interviewed facility staff, resident and record reviews. During the investigation, it was determined that there was enough evidence to substantiate Facility is in disrepair. LPA reviewed resident records, conducted interviews and records review. During the investigation LPA concluded that the facility was in disrepair. Licensee reported that the call alert system was is dis-repair with in the last few months. As a result of this investigation, LPA finds allegation to be substantiated

Based on the findings of this investigation LPA finds allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 rules and regulations, Health and Safety Codes, and Welfare and Institutions Code.

An exit interview was conducted and a copy of this report, dated April 13, 2021 was provided, via email and an electronic email read receipt confirms receiving this document.