complaint·January 13, 2023

The investigation revealed of the following: In regard to the allegation of “Resident sustained an witnessed fall resulting in a broken bone.” All staff denied the allegation and reported staff found R1 was in a kneeling position in the side of the bed and R1 did not want to get up, staff gave R1 time and came back and saw R1 was on the floor scooting to the restroom. Staff also reported R1 often slept partially off the bed, so it was not particularly unusual to see R1 kneeling by the bed. R1 was also able to ambulate for a full day following when the staff found R1 kneeling by the bed and witnessed R1 scooting to the restroom. Based on the interviews conducted with staff and residents and record review, Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the complaint investigation of the allegations are all UNSUBSTANTIATED. An Exit Interview was conducted. The copy of the report and appeal right were provided to MSW Lynn Palin The investigation revealed of the following: In Regard to the allegation “Staff did not seek resident timely medical attention.” It was reported that staff did a visual body assessment when R1 fell but no documentation on the communication log or generate any incident report or notify any family or upper management about R1’s fall because staff reported it was not uncommon for R1 to feel pain. The next staff from next shift also reported that was nothing was reported regarding R1’s pain or fell. Although once R1 complained of pain, facility nurse did the assessment again for R1 and initialed called to the doctor to order the X-ray and they read the result and immediately sent R1 to ER. Based on interviews which were conducted with staff and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the MSW Lynn Palin along with the Appeals Rights.