Complaint Investigation Report

Based on interviews conducted during the course of this investigation, it was learned that there wasn't a cohesion within the core group of facility caregivers, which there were (3) main facility staff persons at this time. It was learned that on at least (1) occasion, the oncoming staff came on and discovered that the scheduled staff for the previous shift had left the facility without notification to the oncoming shift or the facility administrative team. It was learned that the facility residents had been left alone, without any facility staff care and supervision, for an unknown amount of time before the oncoming shift finally arrived to take over.

It was learned that there were notifications, in the form of phone calls and text messages, that were exchanged with the facility designated Administrator in regards to this incident.

Based on interviews conducted during the course of this investigation, it was learned that there was evidence to support that facility residents were left in soiled depends for extended periods of time leading to the development of pressure injuries and other health related injuries. It was learned that these other possible injuries led facility residents to be diagnosed with Urinary Tract Infection (UTI) as well.

It was learned that these types of incidents would lead facility staff persons to have several verbal exchanges, which were highly unprofessional, to take place in front of the residents at times. It was learned that facility staff persons would raise their voices, yell, and even use profanity as well while all in the presence of the facility residents.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated representative at this time.