complaint·April 15, 2025

Allegation: Resident sustained an unexplained fracture while in care Investigation Finding: Substantiated During investigation, the department conducted interviews of residents (R1, R2, R3), facility staff (ED, S1, S2) & R1’s responsible party (POA) and reviewed resident (R1) documents. Review of R1’s records showed she was first admitted at the facility on 03/08/24 and resided at the facility for a couple of months. R1 was assessed as having dementia, ambulatory with a walker, needs assistance transferring in & out of bed, dressing and a high risk for falls. On 04/14/24, R1 was diagnosed with a displaced fracture of the left wrist. R1 stated that she hurt her left wrist at the facility when she fell out of bed. Staff (S1, S2) stated R1 had three falls at the facility (2 unwitnessed falls at night and one unwitnessed fall in the daytime) while at the facility. S2 stated that he found R1 on the floor on 2 separate occasions. R1 did not complain of any pain and helped her get back to bed. S2 confirmed that there were no fall precautions in place after R1’s repeated falls and that her repeated falls were not documented. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that resident sustained an unexplained fracture while in care 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 hospitalization and sustaining unexplained injuries while in care. Additional civil penalty determination is pending relating to resident’s serious bodily injury. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Resident sustained unexplained injuries while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of residents (R1, R2, R3), facility staff (ED, S1, S2, S3) & R1’s responsible party (POA) and reviewed resident (R1) documents. S1 and R2 denied hitting R1. Staff (ED, S1, S2) confirmed that R1 sustained unexplained injuries while at the facility. S3 stated that on 05/21/24 at around 0710 AM she observed R1’s face was bruised with her lip slightly bleeding. S3 observed R1 sitting in her chair instead of sleeping on her bed while R1’s roommate (R2) was sleeping in R1’s bed instead. S3 stated that she asked R1 what happened and R1 stated that R2 hit her. Staff notified R1’s POA about the incident. Later at breakfast, S3 stated that R1 changed her story and said that staff (S1) hit her instead of R2. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident sustained unexplained injuries while in care is unsubstantiated. Allegation: Staff did not ensure resident’s diapering needs are being met in a timely manner Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s bowel movement/pee records dated 03/10/24 until 05/28/24 showed staff assisted R1 with her toileting needs and changed her diapers frequently (3 to 6 times per day). Staff (ED, S1, S2) stated that they showered, changed residents’ diapers/clothes based on their preferred daily and weekly personal hygiene schedules which they recorded each month. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure resident’s diapering needs are being met in a timely manner is unsubstantiated. Continued on next page, LIC 9099-C pg3 Allegation: Staff does not ensure resident’s showering needs are being met Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s monthly shower schedules dated 03/10/24 until 05/28/24 showed that staff gave R1 showers according to family schedules on 03/10, 03/11, 03/15, 03/16, 03/19, 03/23, 03/26, 03/27, 03/31, 04/01, 04/09, 04/09, 04/14, 04/23, 04/24, 04/29 and every Monday, Wednesday and Friday for the whole month of May 2024. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure resident’s showering needs are being met is unsubstantiated. Exit interview conducted and a copy of this report provided.