complaint·February 19, 2025

Allegation: Staff pushed resident resulting in resident sustaining injuries. Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff (ED, S1, S2, S3, S4), residents (R1, R2, R3, R4), R1’s responsible party (POA), third party witnesses (W1, W2) and reviewed resident (R1) documents. Review of R1’s records showed she was first admitted at the facility on 03/03/22 and resided in the memory care unit due to dementia. On 02/16/24 around 0600 hours, R1 exhibited exit-seeking behaviors by attempting to leave the facility through one of the back doors of the memory care unit. S1 attempted to stop R1 from leaving which started an argument. R1 acted aggressively against S1 by yelling racial slurs and by pushing/shoving her walker into S1. S1 reacted by pushing R1’s walker back into the resident causing her to fall resulting in R1 sustaining a close compression fracture of the L-4 vertebra and forehead contusion. Another staff (S2) stated she witnessed the entire incident. S2 stated that S1 pushed R1 in an aggressive manner, that it was not an accident. Other staff (S3, S4) stated that when they arrived at the incident, S1 told them that R1 pushed her walker at her so she pushed R1’s walker back at her. S1 admitted she pushed R1 but did not intend for her to fall. In addition, S2 stated S1 used both hands aimed at R1’s collar bone to aggressively push R1 down. Afterwards, S1 gathered her belongings and left the building without helping R1. 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 staff pushed resident resulting in resident sustaining injuries was found to be substantiated. Immediate civil penalty of $500 assessed during visit for staff physical abuse of resident while in care. 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.