complaint·September 30, 2024

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted with Harmony Venturelli. A copy of this report and appeal rights provided. R1 was evaluated by facility nurse and R1 was alert and responsive, able to display range of motion in all extremities, able to stand and bear weight with assistance, but complained of mild right shoulder pain. Hospital records revealed that R1 was found to have a fracture on right proximal humerus. R1 was medically cleared to return to the facility after a couple days at the hospital. On 4/30/2023, R1 was sent out to the hospital due to shortness of breath. Medical records revealed that R1’s tongue rolled up which obstructed airway. The CT exam showed no signs of intracranial hemorrhage. R1 returned to the facility with hospice services on 5/1/2023. Hospice records revealed that R1 had regular difficulty swallowing medication and food which lead to a decline in health. R1’s death certificate indicated the cause of death was vascular dementia. Resident sustained severe injuries due to staff neglect Interview with staff indicated that R1’s fall was an accident and R1 have not fallen off the wheelchair before. S2 stated R1 was known to lean forward and to prevent R1 from falling off the wheelchair, staff would place pillows on R1’s side. When S2 was taking R1 to the room to change diaper, R1 leaned forward and fell off the wheelchair into her right side. S2 was unsure how R1 fell because R1 had pillows on her sides. Facility staff have conducted training on dementia care, alternatives to restraints in elder care, proper positioning, safe transfers, and falls in assisted living. Staff handled residents in a rough manner Interview with staff revealed that they have not witness staff being rough with residents. Interview with resident indicated that staff are very nice and polite people. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.