Complaint Investigation Report

The investigation revealed the following:

Allegation: Licensee did not comply with requirements for retaining a resident with a restricted health condition.

It is alleged that C1 has a restricted health condition and facility does not have proper care plan for C1’s new condition. LPA obtained copies of the South Central Los Angeles Regional Center Individual Restricted Health Condition Care plan and additional Health Care Plan for C1 and the plan explained that C1 has a Home Health Nurse that will visit client 2-3x a week for catheter care and the facility has a staff that is a registered nurse that will provide the care (if needed) on the other days. Per hospital discharge paperwork C1 was discharged with a Urethral Structure (catheter) on 11/10/25 and was provided with Home Health Services to provide the proper care for C1. LPA interviewed 6 staff and each denied the allegation and stated that although C1 does have a restricted health condition, only the Home Health Nurse or Facility Nurse provide assistance/care for C1’s restricted condition. Interview with S5 revealed that they are a registered nurse and there are other staff at sister facilities that also hold a RN Certificate that are properly trained and qualified to provide the needed care for C1’s condition, additionally S5 stated they visit with C1 about 3 days weekly and/or as needed. LPA reviewed S5’s RN Certificate which is valid with an expiration date of 10/21/26.

Allegation: Licensee did not ensure staff were adequately trained to provide care to residents.

It is alleged that staff are not properly trained to assist with catheter care or hoyer lift. LPA interviewed 6 staff and each denied the allegation, 5 out of 6 staff stated they are not trained to assist with C1s catheter care but there is a nurse that visits almost daily to provide assistance with the catheter. 3 of the 6 staff interviewed stated they are new and have not been trained on using the hoyer lift but have been shadowing and assist a staff that is fully trained if hoyer lift use is needed. S1 stated that the hoyer lift is not something they use daily or regularly and only need to use when a client is too weak to assist with transfers. LPA reviewed the Hoyer Lift in-service training and it showed that on 7/12/25, 7/15/25, 8/28/25 and 9/5/25 there were training's held that covered Safe transfers with a Manual Hoyer Lift, there was a total of 13 staff that have completed the training. LPA interviewed 3 clients and 3 out of 3 clients denied the allegation and stated that they feel staff are properly trained to provide the care they need.