complaint·November 18, 2025

LIC9099-C (Page 2) Allegation: Resident sustained a broken arm while in care Investigation Finding: Unsubstantiated The Department found that on 10/10/2024, at or around 0555 hours, S1 found R1 on the floor of R1’s kitchenette when conducting an incontinence check. R1 reported that they had gotten up to get something to drink on their own. R1 did not press their pendant to request staff’s help. S1 called the overnight supervisor S2, who responded and assessed R1. R1 complained of pain and injury to their head and left arm. R1 was transported to John Muir Medical Center via ambulance. While in the ambulance, R1 reported that they stood up to try to get a pill and fell landing on their left shoulder and face and was unable to get up. R1 was also found to have a Urinary Tract Infection (UTI). R1 underwent a Computed Tomography (CT) scan, which showed a fracture of the left humeral head, neck, and proximal diaphysis. R1’s face was also bruised on the left side as well as their left shoulder. R1’s responsible party is aware of at least six falls and said most of R1’s falls were due to a history of UTIs. R1 has a wrist pendant that they can press to alert and request staff’s assistance. W1 stated that there are no real fall prevention methods in place for R1 other than frequent checks, escort assistance, and the wrist pendant. Staff interviewed vaguely recalled details of R1’s fall from 10/10/2024, but stated R1 got up on their own and did not press their pendant button to ask staff for help, despite being bed bound and unable to stand up or walk on their own. S2 said a family conference would be held and a resident’s care plan would be amended to add additional services when a resident falls more than three times within a 30-day period. LIC9099-C Continued... LIC9099-C (Page 3) The Department reviewed R1’s file and observed that while the MD report indicates R1 to have been a fall risk, there was no documented fall between 2/1/24 and the subject incident of 10/10/24. The records also indicate that from 9/1/24 and 11/30/24, there was 1 fall (the subject incident). The Department found that information obtained was insufficient to confirm that staff had not performed a need which resulted in the fall, injury, and hospitalization. Staff schedule indicates that 6 care staff were on duty at the time of the incident. The Department has investigated this allegation and although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the subject incident was specifically due to neglect. Therefore, the allegation is Unsubstantiated. Allegation: Facility failed to provide adequate care to resident Investigation Finding: Unsubstantiated The Department reviewed documentation indicating that R1 has sustained 16 falls at the facility since their admission in 2022. One Unusual Incident Report, dated 10/10/24, indicated that a caregiver found R1 on the floor in their room during an incontinence check. R1 complained of head and left arm pain/injury. Staff #3 (S3) contacted Staff #4 (S4), who then called 911. No other incidents were documented between 09/01/24 and 11/30/24. A review of R1’s Physician’s Report (dated 12/21/23) and Bi-Annual Assessment, (dated 12/03/24), indicates that R1 diagnosis is sepsis due to Urinary Tract Infection (UTI), has a history of frequent falls, history of Cerebral Vascular Accident (CVA) LIC9099-C Continued... LIC9099-C (Page 4) and utilizes multiple assistive devices, including glasses, half bed rails, hospital bed, pendant, raised toilet seat, shower bench, walker, and wheelchair. R1 cannot ambulate without assistance and requires staff to escort them for 30 minutes per day due to concerns regarding balance and gait. Records further note that R1 has sustained two or more falls within the past year, has expressed fear of falling, and has sustained injuries as a result of previous falls. It was also documented that R1 was not participating in the “Safely You Fall Monitoring Program.” Since admission on 04/22/22, R1 has sustained a total of 16 falls: five in 2022, seven in 2023, three in 2024, and one in 2025. On 11/18/25, record review and interviews with S1 and S2 confirmed that R1 was identified as a fall risk at admission. S1 stated that the community protocol requires a discussion with the resident’s responsible party if three falls occur within a 30-day period. S1 reported that R1’s falls did not meet this threshold, as they occurred sporadically. S1 further stated that staff implemented alert charting, full assessments, and hourly checks for R1. Safely You was offered to the responsible party, who declined participation. S1 also stated that R1’s current care plan includes “Full Care” for ADLs, medication management, continence care, and escort services. LIC9099-C Continued... LIC9099-C (Page 5) Based on records review, interviews conducted, and observations made, the Department has investigated the above allegations of “Resident sustained a broken arm while in care” and “Facility failed to provide adequate care to resident” to be unsubstantiated. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations of Resident sustained a broken arm while in care and Facility failed to provide adequate care to resident is Unsubstantiated . Exit interview conducted and a copy of this report provided.