complaint·March 26, 2025

Regarding the allegation: Resident sustained a fracture while in care. It is being alleged that resident #1 (R1) sustained a cervical neck fracture. On 08/20/24, IB conducted a facility visit and received the following documents: August Staff Schedule, Staff Roster with contact information, Facility First Second Floor Facility Map, Daily Census, Unusual Incident/Injury Report, R1's File containing the following: Preplacement Appraisal Information, Functional Capability Assessment, Resident Appraisal, Appraisal /Needs and Services Plan, Personal Rights of Residents in Publicly Operated, House Rules, Guest Policy, Medication Disclosure and Policy, Private Caregiver, Home Health Agency, and Hospice Disclosure and Policy, Statement of Informed Choice, Unsupervised Absence Disclosure, Ambulation and Mobility, Dementia, Residence and Care Agreement, and Admission Agreement record review of hospital records from Kaiser Permanente. Furthermore, IB conducted interviews. On 10/08/24, IB conducted another facility visit and interviewed additional staff and was informed that R1 might have had an unwitnessed fall during the night that caused the cervical fracture. The investigation revealed the facility’s Neglect/Lack of Supervision contributed to the development of R1’s cervical fracture. Based on the observation of the IB Investigator, interviews conducted, and record review the allegation is SUBSTANTIATED at this time. An immediate Civil Penalty of $500.00 is being issued today, due to the staff’s negligence. Refer to LIC 421M. At this time, an Enhanced Civil Penalty (ECP) determination is pending and may be assessed at a later date. Exit interview conducted, appeal rights discussed, and a copy of the report was given to the administrator.