complaint·August 24, 2022

On 4/30/2022 at about 10:00AM, staff (S6) found resident (R1) on the floor, S6 stated that she called another staff (S5) on duty to assist her on picking R1 up. S5 stated that prior to 4/30/2022 fall incident, he found R1 on the floor twice, but he never reported these incidents to Administrator. On 5/2/2022, S7 told S3 that R1 was complaining of pain during his shift (night shift), S3 stated that before he started his shift, he checked on R1 and found R1’s right leg swollen and bruised. S3 contacted the Administrator and informed her that R1 needs medical attention, Administrator advised S3 to call 911, but decided to wait for Assistant Administrator (S2). Based on records review, on 4/30/2022 at about 2:10PM, staff (S2) informed S1 about R1’s legs that it was painful when touched. S1 have knowledge of R1’s leg condition. Based on hospital records, R1 was diagnosed with hip fracture. Records review stated R1 was non-ambulatory, needs and appraisal services indicated that R1 had limited mobility due to poor vision and needs transfer assist in getting in and out of bed. Allegation: Staff did not seek timely medical attention for resident Based on interview and records review, on 4/30/2022 at about 10:00AM resident (R1) was found on the floor. Based on interview S5 stated that prior to 4/30/2022 incident with R1, he found R1 on the floor twice, but was never reported to Administrator nor seek medical attention. Staff did not call 911 not until 5/2/2022 when S3 found bruises and swollen right leg on R1. Based on records review, on 4/30/2022 at about 2:10PM staff (S2) sent a picture of R1’s leg to S1 and informed her that it was painful when touched. On 5/1/2022 at around 1:31AM, staff (S7) informed S1 that R1 was complaining of right leg pain, on 5/1/2022 at around 7:18PM, staff (S2) sent a picture of R1’s leg to S1 showing R1’s bruises on her leg. R1 was not sent to hospital not until 5/2/2022. Allegation: Staff did not notify resident's authorized representative of incident Based on interview and records review, S5 stated that prior to 4/30/2022 incident, he found R1 on the floor twice, but he never reported these incidents to Administrator or to authorized representative, R1’s fall incidents was not reported to F1 not until R1 went to the hospital on 5/2/2022. The preponderance of evidence has been met. Therefore, the allegations above are substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. A Non-Compliance Conference (NCC) will be scheduled at a later time. Exit interview conducted. Appeal Rights and a copy of this report provided via email to Administrator.