Complaint Investigation Report

Based on photos, observation, records review and interviews, facility call light is inoperable for facility staff to respond to residents. On February 19, 2025, LPA reviewed the call light system screen, and the screen showed Room 135 waiting 29 minutes, Room 106 and Room 126 waiting 2 hours. During today’s visit, call light are currently not working properly, so Administrator called over radio for staff to respond when LPA Kaur pulled the call light for Room 107. Staff responded in 14:42 minutes. LPA interviewed staff and based on interviews when there are 3 caregivers on shift there is enough staff but when there are two caregivers on shift there is not enough staff to meet the needs of the residents. LPA reviewed staff schedule and observed several days with only two caregivers on shift.

Based on records review and interviews, it was found staff do not have the knowledge to recognize and respond to problems . R6 had blood sugar readings in between 300 to 560 with no restricted health care plan indicating when R6 should be sent to the hospital. LPA obtained copies of the blood sugar readings from 11/24/24 to 12/28/24.

Based on interviews, records review, observation and photos, the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

An exit interview was conducted and a copy of this report along with appeal rights and plan of correction were provided.