complaint·September 15, 2022

The investigation revealed the following; Allegation: Facility did not inform responsible party of change in resident's condition. The details of this allegation states that the family of R1 was not notified after R1 sustained a fall on 9/8/22. Based on interviews conducted, the statements obtained were consistent and corroborated with the allegation. Interviews conducted with staff and records reviewed confirmed that R1 sustained a fall on the morning of 9/8/22, at 5:30am. Facility staff failed to inform the family regarding the fall incident involving R1. Facility staff notified the family of R1 regarding a separate incident which occurred on 9/9/22, where R1 was transferred to Huntington Memorial Hospital, where she remains hospitalized. During today's visit, LPA obtained a copy of the UPDATED Unusual Incident/Injury Report dated 9/15/22, notifying CCL/Licensing of the fall incident (9/8/22) involving R1. Based on the investigation conducted, LPA found sufficient evidence to support this allegation to be true. Based on LPA’s observations and interviews which were conducted and record reviews, 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 Administrator along with the Appeals Rights. The investigation revealed the following; Allegation: Resident did not receive medical attention as needed. The details of this allegation states that R1 was not sent to the hospital after she sustained a fall. Based on interviews conducted and records reviewed, the statements obtained were inconsistent and did not corroborate with the allegation. Staff interviewed denied not sending R1 to the hospital after R1 sustained a fall. R1 sustained a fall on the morning of 9/8/22, at 5:30am. R1 was seen by her Physician on 9/8/22, at 10am, at which time the Physician advised to keep an eye on R1 and if R1's symptoms worsen to take R1 to the ER. On 9/9/22, at 11:10am, facility staff observed a decline in R1 condition and transferred R1 to Huntington Memorial Hospital (E.R.), per Physician's instructions. Based on the investigation conducted, LPA found insufficient evidence to support this allegation to be true. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided.