complaint·February 20, 2025

ALLEGATION: Neglect/Lack of Supervision – Staff did not provide adequate supervision resulting in resident (R1) sustaining multiple fractures while in care. INVESTIGATION FINDING: Substantiated During investigation, the department conducted interviews of facility staff (Care Director (CD), Regional Health Services Director (RHD), S1, S2) & R1’s responsible party (POA) and reviewed resident (R1) documents. Review of R1’s incident reports showed R1 had sustained 5 documented falls at the facility since she was admitted in 2022. Staff (CD, RHD) both denied receiving reports from care staff that R1 needs a 1:1 caregiver citing R1 higher level of care. Despite having multiple fall prevention methods in place and staff expressing their concerns to management in not being able to provide adequate care, R1 continued to have un-witnessed and witnessed falls in the facility, twice sustaining serious fractures in her femur and pelvis, Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not provide adequate supervision resulting in resident (R1) sustaining multiple fractures while in care. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated. Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in resident sustaining multiple fractures while in care. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) 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.