However, in the case that staff are helping another resident in their room, this feature might be challenging for staff. Based on records review of R1’s physician report dated 5/5/2021, R1 needs assistance with daily activities including incontinence care and transfers to and from bed. Also, LPA was provided with a staff schedule for the month of January 2024 that indicates that there were two staff on duty on 1/28/24, but one of them was taking their lunch break at the time of the incident. Interviews conducted with staff (S1 and S2) and residents in care (R1, R2 and R3) revealed conflicting information if R1 had a call pendant at time of incident. Interviews conducted with R2 revealed no information to confirm yelling for assistance. Interviews conducted with S1 revealed that R1 requested a few minutes of privacy while using the restroom. I t was confirmed that S1 came back to assist R1 within approximate five minutes after assisting another resident who was in the living room, at the other end of the facility. Although R1 had a fall, the investigation did not reveal information of neglect and lack of supervision. A finding that the complaint allegation of neglect and lack of supervision resulting in injury is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding the allegation of staff unable to meet resident care needs. Per reporting party, staff would usually not check in with R1 when help is being asked. Based on records review, the facility issued an unlawful 30-day eviction notice to terminate board and care services to resident (R1) dated 4/22/2022 that was not enforced by the facility when the effective date of eviction 5/22/2022 was reached. Per eviction notice, R1 needed a higher level of care and supervision including assistance with their daily activities that the facility was not able to provide to them. Based on interviews with the licensee, R1’s responsible party was unable to find placement, so both parties verbally agreed that R1 will stay in the facility receiving the same services that they were unable to provide that could risk the health and safety of R1. Per Title 22 regulations reasons for eviction were unlawful. Although the unlawful eviction notice indicated they couldn’t meet R1’s needs, there is not a valid reason within regulation that could possible evict R1. Upon admission, it appears R1’s care needs were similar, and no change of condition has been able to be identified. A finding that the complaint allegation of staff unable to meet resident care needs is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Licensee and copy of this report was given.