complaint·December 2, 2025

Allegation: Facility staff are not properly reporting incidents Regarding the allegation, “facility staff are not properly reporting incidents,” it is being alleged that only two out six falls were reported for Resident #1. It is also alleged that the paperwork was not completed accurately since one fall resulted in an emergency room visit. Record review of clinical view report revealed R1 tripped (03/10/25) and fell (03/28/25; 04/12/25; 04/30/25). Responsible party/parties were notified on all four dates including the incident associated with the emergency room visit (04/12/25). Ten out of ten staff interviews (S2 - S3, S5 – S12) indicated that incidents are reported to the appropriate parties and are documented. Director of Nursing indicated families are contacted, the doctor is informed, and notes are made in the facility’s charting system. Witness #1, R1’s responsible party, indicated that the facility generally calls to report incidents. Four out four witness/responsible party interviews (W2 – W3, W5, W7) indicated that the facility staff report resident incidents. Regarding the allegation, “facility staff are not properly reporting incidents,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation: Facility staff are not ensuring resident receives podiatry care as needed. Regarding the allegation, “facility staff are not ensuring resident receives podiatry care as needed,” it is being alleged that Resident #1 has not received services since 02/24/25. It is alleged that R1’s Physician ordered daily foot care services on 05/16/25 and R1 has yet to receive services as of 10/14/25. Record review of Podiatrist encounter notes revealed R1 received services on 02/24/25, 05/04/25, and 10/10/25. Podiatrist Progress notes revealed R1’s nails were clipped on 09/04/25. Torrance Memorial (05/16/25) note revealed R1 is to receive daily foot care and podiatry evaluation every two months. Torrance Memorial (07/15/25) response note revealed R1’s feet is to be evaluated daily for sores, redness, dryness and to call with abnormal finding and provide nail clipping as needed. Eight out of eight staff interviews (S2, S5 – S7, S9-S12) indicated that residents receive podiatry services once every other month. Director of Nursing/S1 and S3 indicated that care partners do the daily care, notify the nurse, and will request a PRN or scheduled visit. S1 also indicated that R1’s August 2025 podiatry visit was pushed to 09/04/25 due to the Podiatrist’s schedule. S10 and S13 indicated they evaluate R1’s feet and look for redness, bumps, dryness, skin tears, and observe R1’s nail. S10 indicated that most reports are regarding nail length. Continue to LIC9099-C. Witness #1, R1’s Emergency Contact, indicated that the facility does have a podiatrist come but R1’s feet are not being cared for enough. W1 indicated that the Practitioner sent a note for daily foot care but W1 is not sure if R1 is receiving it. Four out four witness/responsible party interviews (W2 – W3, W5, W7) indicated that podiatry care is provided to residents. Regarding the allegation, “facility staff are not ensuring resident receives podiatry care as needed” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted and a copy of this report was provided to the Director of Nursing Janie Acosta.