complaint·March 11, 2025

It was alleged that on 02/22/2025, Resident #1 (R1) was hit with a facility door by Staff #1 (S1). S1 opened the double doors leading to the staff area at 08:01AM and was unaware that R1 was behind the doors. R1 fell and hit their head, resulting in bruising and a laceration on the right side of their face. Paramedics were called and family was notified by the facility immediately. R1 did not sustain serious injuries. During today’s visit at 10:50AM, LPA observed caution signs taped to the doors on the staff side that state “ATTENTION: PLEASE OPEN DOOR WITH CAUTION.” Per interviews, staff have been advised to open the door cautiously and to redirect R1 when R1 is observed to be near door paths. Record review and observation of R1 indicate that R1 has dementia and wandering behaviors. Staff are knowledgeable in redirecting R1. At 12:49PM, LPA observed R1 with a small pale green bruise under their right eye by their nose, slight redness above the right eyebrow, and no swelling or significant bruising. Lack of supervision, malicious intent, and concerns of negligence were not noted. It was further alleged that the facility door poses a safety concern for residents as there are no windows or cameras to alert staff if residents are in the way of the door. At this time, there are no regulations in the California Code of Regulations, Title 22 and/or California Health and Safety Code that require facility doors to have windows, cameras, or other equipment for staff to observe if residents are behind a door. LPA had a conversation with ED about minimizing the risk of reoccurrence as the door is heavy and requires force to open which could be problematic if a resident was in its path. ED informed the maintenance director and stated they will inquire about having a window placed on the door or some other feature that could allow staff to check for residents in the way. During the visit, ED placed additional signs on the community side of the door stating, “CAUTION WHEN OPENING DOOR PLEASE OPEN CAREFULLY PLEASE DO NOT STAND IN FRONT OF THE DOOR.” ED also stated that they will have staff redirect R1 if R1 gets close to the door and ED and HSD will have weekly reminders for staff to open the door cautiously. LPA observed a daily meeting agenda on 02/24/2025 with the goal of informing staff to monitor R1 and open doors cautiously. LPA observed ED reminding staff to open the door carefully at 03:07PM. Information obtained through interview, record review, and observation for this investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations “Staff negligence caused injury to resident” and “Facility door poses a safety concern for residents” are deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.