complaint·October 23, 2025

LIC9099-C (Page 2) Allegation: Resident sustained a fracture due to lack of care from staff Investigation Finding: Unsubstantiated On 12/09/2023 at approximately 0700 AM staff (S1) heard resident (R1) shouting for help, and S1 came to R1’s aid. S1 found R1 sitting on the floor, complaining of back pain while holding onto his hip. S1 did not observe any visible injuries on R1. S1 offered to call 911, but R1 declined and requested assistance to stand. S1 helped R1 back to bed and resumed his duties. Allegation: Staff did not seek medical care for resident in a timely manner Investigation Finding: Unsubstantiated Review of R1’s medical documents, from Kaiser Permanente at Walnut Creek revealed on 12/09/23 at approximately 0330 a.m., R1 sustained an unwitnessed fall. During the night shift, S1 reported the fall to the oncoming day shift caregiver, S2, at approximately 0700 a.m. At approximately 0900 a.m., S2 informed the in-house Registered Nurse (S3) of the incident. S3 provided instructions to S2 over the phone to assess R1. S2 documented no visible marks, bruises, skin tears, or discoloration, but noted that R1 moaned in pain when moved. S3 did not instruct S2 to call 911, nor did S3 advise any additional assessment. The direction provided was to administer pain medication, monitor R1 for one hour, and, if R1’s family did not respond within two hours, arrange transport to the hospital. LIC9099-C Continued... LIC9099-C (Page 3) At approximately 0725 a.m., S2 attempted to contact R1’s family. The call went to voicemail, and a message was left requesting a return call. At approximately 1100 a.m., R1’s daughter arrived at the facility. R1 was transported to Kaiser Walnut Creek Emergency Department at approximately 1200 p.m. Documentation shows that at approximately 1400 p.m., staff were notified that R1 had sustained a hip fracture. Based on records review, interviews conducted, and observations made, the Department has investigated the above allegations of “Resident sustained a fracture due to lack of care from staff” and “Staff did not seek medical care for resident in a timely manner” and found it 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 fracture due to lack of care from staff and staff did not seek medical care for resident in a timely manner is unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.