Complaint·March 21, 2025

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not seek timely emergency medical treatment for resident. Allegation #2: Staff did not notify resident's responsible party of change in resident's condition. The complaint alleged that the facility staff did not seek timely emergency treatment and did not notify Resident #1 (R1)’s responsible party of change in condition. It is reported on January 25, 2025 (R1) had an unwitnessed fall and hit (R1’s) head on the bathroom tub. On January 27,2025, (R1) was found incoherent and with loss of conciseness and in both incidents no medical attention was provided. On February 11, 2025, between 10:15 AM and 12:40 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) acknowledge the incidents occurred with (R1). (S1-S3) claimed the standard procedures are that when a fall occurs, the care staff performs a triage, an assessment is done, and if necessary, 911 is dispatched. (S1-S2) stated that medical attention is requested if the fall involves a head injury. After a fall, the registered nurse monitors the resident for seven consecutive days. (S1) claimed was unaware of the fall on January 25, 2025, while (S2) was not on duty and was only made aware of the incident by staff. (S1-S2) both admitted that medical attention was required as the fall with (R1) involved a head impact. On March 21, 2025, between 12:15 PM and 12:55 PM, the Department interviewed a staff member identified as Staff #4 and Staff #5. Two (2) out of the two (2) staff members (S4-S5) stated they was aware of (R1)’s fall and no medical attention was provided ordered by (R1). (S4) stated that the family representative of (R1) was notified and refused medical attention following the fall. (S4-S5) reported caregivers are trained to respond to resident falls. The on-duty supervisor assesses the resident and decides if medical attention is needed, especially in head impact cases. Two (2) out of the two (2) staff members identified as Staff #2 and Staff #4 were only made aware of (R1) 's change in medical condition on January 28, 2025, by (R1) 's family representative who informed them about the resident's change in condition. (S2 and S4) claimed they did not notice (R1)'s decline or seek medical attention until the family representative informed them that (R1) was incoherent and had lost consciousness. On March 21, 2025, between 10:00 AM and 11:07 AM, the Department conducted interviews with resident members identified as Resident #1 through Resident #7 (R1-R7). Four (4) out of the seven (7) residents reported experiencing falls while in care at this facility. They indicated that they received appropriate care from staff and did not require any medical attention. (Evaluation Report continues LIC 9099-C) INVESTIGATION REVEALED THE FOLLOWING: Allegation #3: Staff did not provide resident with food. Allegation #4: Staff did not provide resident with fluids. The complaint alleged that the facility staff did not provide Resident #1 (R1) adequate food and fluids. (R1)'s recent hospitalization required monitoring of food and fluid intake. No additional information was provided concerning these allegations. On February 11, 2025, between 10:15 AM and 12:40 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the (3) staff members denied the claim. (S1-S3) explained that (R1) receives three meals daily without a special diet. Along with the meals, a variety of liquid fluids are provided. All residents are offered a daily 60 oz pitcher of drinking water. According to (S1), the meals are both nutritious and have been approved by dieticians at Calson Management. (S1-S3) reported with (R1)'s recent hospitalization, (R1) was medically reassessed, and the service plan was updated. (R1) returned from the hospital on February 1, 2025, and was monitored by care staff daily through February 10, 2025. On March 21, 2025, between 12:15 PM and 12:40 PM, the Department interviewed a staff member identified as Staff #5. (S5) claimed to be one of the primary care staff for (R1) and verified that (R1) was being monitored routinely after (R1)'s hospitalization. (S5) claimed that it was challenging oftentimes when it came to meals as (R1) preferred only a Cheeseburger, and if (R1) was not provided that request, they would refuse to eat. (S5) also stated that (R1) preferred only to drink sodas and that water was not of preference and would have to make (R1) must do better on water intake. On March 21, 2025, between 10:00 AM and 11:07 AM, the Department interviewed resident members identified as Resident #1 through Resident #7 (R1-R7). Seven (7) out of the seven (7) residents claimed to have no issues or concerns with lack of meals and fluids. (R1-R7) all verified the facility provided three meals daily and fluids are provided with meals. (R1-R7) confirmed that care staff provided residents with daily water pitcher and it refilled in the afternoon. (R1) reported to have a preference for cheeseburger and soda for liquid drinks and claimed (R1) needed to better at consuming water. (Evaluation Report continues LIC 9099-C) The Department reviewed (R1)'s Progress Notes (dated 01/26/25 through 02/10/25) and revealed that (R1) was being monitored for food and liquid consumption. A review of (R1's) Physicians Report LIC 602 (dated 05/20/24 and 02/04/25) and Service Plan (dated 11/05/24 and 02/05/25) made no indication that (R1) is on a special diet. An additional review of the facility's menu (dated 03/01/25 through 03/31/25) revealed that certified board nutrition specialists approve meals. Upon further review of (R1)'s Medication List (dated 02/05/25), it was noted that two (2) of the nine (9) prescribed medications has side effects related to loss of appetite (ref. National Institutes of Health). The Department observed (R1) was supplied with a bedside water pitcher on both visits on February 11, 2025 and March 21, 2025. Based on the gathered information, insufficient evidence supports the stated allegations. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted with Chanel Sanchez, and copies of the reports were provided. Resident #1 (R1) recalled having a fall but did not believe that medical attention was necessary at the time. However, (R1) did remember hitting their head on the bathroom tub during the fall. Six of the seven residents, identified as Resident #2 through Resident #7, stated that the staff are attentive in observing any decline or change in a resident's condition. (R1) mentioned being hospitalized after the fall, but only after a family representative requested medical attention. (R1) noted a change in condition due to symptoms of a urinary tract infection that staff should have noticed. The Department reviewed (R1)'s Progress Notes (dated 01/26/25 through 02/10/25) and revealed that had fall with head impact on January 26, 2025 and 911 was not ordered. It also revealed that on January 28, 2025, facility staff was ordered by the family representative to call for paramedics due to the change with (R1)'s condition. Further review of (R1)'s Medication List (dated 02/05/25) revealed nine (9) out of the nine (9) prescribed medications all had side effects of dizziness, anxiety, confusion, seizure or fainting (ref National Institute of Health) symptoms could contribute to falls. Upon reviewing the available information, it is evident that the facility failed to comply with its established fall prevention protocols. In this instance, immediate medical attention was not sought for resident (R1) following a fall that resulted in a significant head impact. Such an oversight in care is concerning, as prompt hospitalization could have revealed that the resident may have been experiencing a urinary tract infection. This condition can lead to further complications if left untreated. This lapse underscores the critical importance of adherence to safety guidelines and the need for timely intervention. Based on observations, interviews, and record reviews, the preponderance of evidence standard for "NEGLECT and LACK OF CARE AND SUPERVISION" has been met. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Chanel Sanchez, the Executive Director. During the interview, a hard copy of the report and information on appeal rights were provided.