Complaint Investigation Report

Allegation: Facility failed to seek resident medical attention for fall

Based on interviews and record reviews, staff failed to seek resident (R1) medical attention for fall (11/07/20). Administrator stated R1 has loose urination and tended to urinate on the floor instead of his commode. R1 tripped on his walker and fell on his face due to the wet floor. R1’s black eye and lump above his left eyebrow did not show until after 2 days. Neutral witness (W1) confirmed staff did not seek medical attention for R1 when fall incident occurred. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Resident has sustained several falls while in care

Based on interviews and record reviews, staff (S1) confirmed with LPA that resident had several falls which he logged on the computer (9/13/20, 9/23/20, 10/18/20, 10/19/20 and 11/07/20. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Resident’s room has feces on the wall

Based on interviews and record reviews, staff (S1) confirmed with LPA that he cleaned R1’s alleged fecal matter smeared on R1’s wall on11/06/20 as instructed by neutral witness (W1) who visited facility unannounced on official business. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.