Complaint·April 18, 2022

Based on IB investigation; it was revealed that R1 alleged R1 was dropped on the floor by staff members, S1 & S2 as they attempted to lift R1 from R1’s wheelchair. During the investigation, R1 was interviewed by CCL/IB (Community Care Licensing Investigation Branch) investigator and R1 disclosed that staff members S1 & S2 attempted to pick R1 up after they observed R1 on the floor next to R1 bed. R1 stated R1 was on the floor because R1 decided to execute what R1 called a "controlled slide" out of R1’s bed. R1 explained that S1 picked R1 up by R1’s legs, while S2 picked R1 up by R1’s hands. R1 stated R1 slipped out of S2 hands causing R1 to fall on the floor. As a result, R1 injured his shoulder. R1 advised S1 and S2 that they injured R1’s shoulder, but they claimed R1 injured R1’s shoulder by falling out of R1’s bed. R1 was adamant that R1 did not "fall" out of R1’s bed. R1 "slid" out of R1’s bed, which did not result in injuring R1 shoulder. During the investigation, it was revealed that R1 had informed several different sources (a family friend, hospital staff, and additional staff members at the facility) that it was facility staff that caused R1 injury. Both S2 & S1 deny dropping R1 but acknowledged attempting to pick R1 up off the floor but was unable to because R1 was too heavy. Per the medical records, it indicated R1 indeed sustained a "Mildly Displaced Fracture of the Proximal Humerus Extending to the Greater Tuberosity." It appears more likely than not that the injury sustained to R1’s shoulder was the result of R1 being dropped by facility staff. Therefore, the Allegation 1 – resident sustained a fracture while in care is "substantiated" at this time. Allegation # 2 – Facility failed to seek timely medical attention – During IB investigation; it was revealed that R1 alleged R1 was dropped on the floor by staff members, S1 & S2 as they attempted to lift R1 from R1’s wheelchair. During the investigation, R1 was interviewed by CCL/IB (Community Care Licensing Investigation Branch) investigator and R1 disclosed that staff members S1 & S2 attempted to pick R1 up after they observed R1 on the floor next to R1 bed. After the incident R1 complained of pain in R1's shoulder, staff only provided pain medication. Staff did not send R1 immediately after incident, staff waited several days after incident to send R1 to the ER only after R1 insisted on being sent to the ER Therefore, the allegation is substantiated. Allegation 3 – facility has insects. The Interview conducted with Executive Director, he stated that the facility did have cockroaches in the facility. Orkin pest control came to spray the facility on the 3 following dates: 09/02/20, 11/17/20, & 12/04/20. LPA reviewed Orkin pest Control invoices for those dates. The cockroaches had been eliminated from the facility. Therefore, the allegation is substantiated. Based on Investigator Douglas observations and interviews which were conducted and records reviewed, violations were found and are being cited on the attached LIC 809D per Title 22, Division 6, Chapter 8 of the California Code of Regulations; and an immediate Civil Penalty in the amount of $500.00 issued, although an enhanced civil penalty is being considered. A ccording to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations. An exit interview was conducted with James Bender, Vice President and a hard copy of report was provided along with Appeal Rights.