complaint·March 29, 2023

Division’s Investigations Branch (IB). The investigation consisted of interviews with R1’s family members, facility Executive Director, Health Services Director, Memory Care Director, two (2) Resident Coordinators, two (2) Medical Technician's, Hospice Nurse, two (2) Facility Care Providers, two (2) Private companions (hired by R1's family), Housekeeping, R1's records review - included but not limited to physicians report (signed and dated on 01/11//2019 - 04/14/21 and 10/21/22), resident care notes (from 04/29/21 to 10/06/22), 1st Hospice care plan (dated as of 10/22/2022), 2nd Hospice care plan (dated as of 10/10/22) and other relevant documentation. Investigator, Santiago, also subpoenaed R1’s Medical Records on 10/13/22 and reviewed on 12/23/22. Allegation: "Resident sustained an unexplained injury in care." The investigation findings revealed that R1 had been living at this facility, in a Memory Care Unit, since April 2021. Interview with R1’s family revealed that R1 continued to have multiple falls from 09/12/22 that resulted in bruising and skin tear. Review of medical records confirmed that on 09/12/22, the facility initiated emergency medical services and resident was later diagnosed with a nasal tip fracture after an unwitnessed fall that staff was unable to explain. In addition, on 10/08/2022, family brought R1 for a doctor’s visit due to unexplained bruising and confirmed that R1 sustained three rib fractures. Lastly, R1 continued to have multiple falls that resulted in bruising and skin tear until R1 moved out of the facility on 10/26/2022, due to hospitalization from another fall. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated. Allegation: "Resident sustained multiple falls due to lack of supervision." Although the family brought on multiple companions for R1, they were not always available and were unsuccessful in preventing falls and reducing injuries. Facility was aware of the R1’s decline, yet interviews and records verified that there were no updated reappraisals or fall plan in place to reflect on managing the resident’s change of condition. Staff revealed inconsistent information on how often they checked on resident. Throughout the course of the resident’s decline, Executive Director advised the family that they don’t have the staffing to meet R1’s needs and suggested getting a one-on-one caregiver or placing R1 in another community more suitable for his/her needs. Although the Executive Director communicated with the family about moving R1, they admitted they were willing to let the family extend their notice, knowing the facility Continue on LIC9099-C could no longer meet R1's needs. Facility neglected to produce an appropriate fall plan and retained the resident, knowing that the facility did not have adequate care and supervision to meet R1's needs. Lastly, the Regional Office received twelve (12) unwitnessed fall incident reports form 09/12/22 to 10/26/22. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated. Allegation: "Facility is not meeting resident's nighttime supervision needs." Interview with R1's family revealed that they were initially told by the facility that R1's room had a motion detector that would alert staff of the fall, but later discovered that it was inoperable. In addition, the family was advised that the facility was going to place a bed alarm that would notify staff when R1 got up, but the facility failed to supply that. Finally, interview with the Executive Director revealed that the family was informed that the facility did not have enough staff to supervise R1 at night and requested the family to provide R1 with one-on-one caregiver or move R1 to another home. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated. A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f). Exit interview conducted. Civil penalties assessed and appeal rights explained. Report reviewed, signed and delivered. Allegation: Facility is not meeting resident's personal hygiene needs. It was alleged that R1 did not shower/shave nor had their teeth brushed due to facility being understaffed. During the subsequent visit made on 02/07/23, LPA conducted a physical inspection in a Memory Care Unit and observed twelve (12) residents in a dining and TV area wearing clean clothes, well groomed and appeared well taken care of. In addition, interviews with the Executive Director and three (3) staff members revealed that the facility provides basic services (grooming, bathing, dressing, etc.) to all residents. Moreover, LPA observation, record reviews and interviews revealed that all hygiene needs are being met and that residents are scheduled to have showers at least two (2) to three (3) times a week or as needed and the facility caregivers are on standby for those who need assistance. Based on interviews, document reviews and LPA observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was provided to the Executive Director.