complaint·April 27, 2026

Investigation Revealed the Following: Allegation: Staff did not ensure supervision was provided to resident resulting in multiple fractures from a fall. The details of the complaint alleged that facility staff did not ensure supervision was provided to (R#1) resulting in multiple fractures from fall. On October 20, 2025, during the records review, the Department observed documentation consistent with the facility’s reporting of the incident and subsequent monitoring of (R#1). On the same date, (R#1) sustained an unwitnessed fall. The facility caregiver conducted rounds at approximately 06:00 a.m. and observed (R#1) in bed, asleep. At approximately 06:40 a.m., during the second rounds, (R#1) was discovered on the bathroom floor of their bedroom and was assessed by the facility nurse with no visible injuries noted. (R#1) was placed on observation. On October 21, 2025, (R#1) appeared to have some pain, and the facility requested X-rays, which were pending from the medical doctor. On October 22, 2025, (R#1) had a visible change in condition and was unable to bear weight, collapsing into the arms of a caregiver. (R#1) was transported to the local hospital and admitted to the emergency room, where they were diagnosed with a large left pneumothorax, moderate left pleural effusion, and mildly displaced left posterolateral fourth through seventh rib fractures. Based on the information reviewed and interviews conducted, there was no evidence that the facility neglected (R#1)’s care. On October 20, 2025, during interviews with witnesses (W#1–W#4), (4) out of (4) stated they had no concerns regarding the care provided to residents in care, including (R#1). Witnesses reported that during their visits, (R#1) appeared well and that they had never observed any indication of neglect by the facility. Witnesses further stated that (R#1) was consistently clean, groomed, and in good spirits. One witness reported making unannounced visits and stated they had never observed neglect of care toward any residents. Another witness stated they had never seen any signs of abuse or neglect by the facility. A witness also stated they had no concerns regarding the care provided, had never had any inclination of neglect, and was satisfied with the type of care the facility provided. Evaluation Report continues LIC 9099-C On October 20, 2025, during interviews with facility staff (S#1–S#4), (4) out of (4) stated that they had no concerns regarding the care provided to residents in care, including (R#1). Staff reported that they had not observed any signs of neglect, abuse, or unexplained injuries and stated that residents appeared well cared for, clean, and appropriately supervised. In addition, (4) out of (4) facility staff further stated that the facility followed established procedures for monitoring residents and responding to changes in condition. Allegation: Staff did not ensure resident received medical attention in a timely manner The details of the complaint alleged that facility did not ensure (R#1) received medical attention in a timely manner. On October 20, 2025, during the records review, the Department observed documentation consistent with the facility’s reporting of the incident and subsequent monitoring of (R#1). On the same date, (R#1) sustained an unforeseen, unwitnessed fall. Facility caregivers conducted rounds at approximately 06:00 AM and observed (R#1) in bed, asleep. At approximately 06:40 AM, (R#1) was discovered on the bathroom floor of her bedroom. (R#1) was assessed by the facility nurse, who noted no signs of injury or indications of a possible fracture. (R#1) was placed under observation for any change in condition. On October 21, 2025, (R#1) appeared to be in pain, and the facility requested X-rays to be completed. The facility arranged for (R#1) to be transported to the local hospital for further evaluation. Allegation: Staff did not observe changes in residents physical health. The details of the complaint alleged that facility did observe (R#1)’s changes in physical health. On April 27, 2026, during the records review, the Department observed copies of (R#1)’s facility staff notes. The Department noted multiple documented changes in condition for (R#1), including an entry dated 10/23/2025 in which staff reported (R#1)’s “color was off” and that the resident “was not making any sense,” after which 911 was called and (R#1) was transported to Cedars ER. The Department also noted documentation of unwitnessed falls on 10/20/2025 and 10/04/2025, with post-fall evaluations and notifications to (R#1)’s responsible party and physician. Evaluation Report continues LIC 9099-C Additional health status notes reflected a broken or missing lower front tooth on 10/5/2025 and a nosebleed on 9/16/2025, both with notifications to the responsible party and physician. On April 27, 2026, during an interview with the Executive Director (A#1), he stated that the facility’s procedures for observing, monitoring, and documenting changes in residents’ physical health, including (R#1), involve the care team documenting observations electronically in their tablets and informing their supervisor when they notice any significant changes in a resident’s condition. (A#1) further stated that when a change in condition or incident requires an incident report, the care team contacts the family or responsible party and documents the incident. He stated that incident reports are then reviewed by the nurses to ensure appropriate follow-up and reporting. On 4/27/2026, the Department could not speak with (R#1) as they no longer reside at the facility. The Department attempted to contact (R#1) using the phone number on file; however, the Department could not reach them. On April 27, 2026, during interviews with residents in care (R#2 through R#9), (8) out of (9) stated that when they are not feeling well or when something about their health changes, staff usually notice and check on them. In addition, residents also stated that staff appear aware of how they are doing day to day, including their energy, appetite, and mobility, with residents reporting that staff “come every day. On April 27, 2026, during interviews with facility staff (S#1 through S#4), (4) out of (4) staff stated that they monitor residents, including (R#1), for changes in their physical condition by conducting daily checks with the care team and observing for changes in mobility, appetite, hygiene, or overall appearance. Staff stated that they document any observed changes. In addition, (4) out of (4) staff further stated that when they notice a change in a resident’s physical health, they are expected to notify the family or responsible party immediately and notify the resident’s physician. Evaluation Report continues LIC 9099-C Allegation: Staff did not ensure reporting requirements were followed The details of the complaint alleged that facility did report to (R#1) representatives on their events. On April 27, 2026, during the records review, the Department evaluated whether staff followed required reporting procedures for changes in condition and incidents involving (R#1). The Department noted multiple entries in which staff documented changes in condition and completed required notifications. This included an entry dated 10/23/2025 in which staff reported that (R#1)’s “color was off” and that the resident “was not making any sense,” after which 911 was called and (R#1) was transported to Cedars ER, with notifications made to the responsible parties and the primary care physician. In addition, the Department observed a copy of (R#1)’s incident report dated 10/23/2025 and noted that when (R#1) sustained a fall on 10/20/2025, the facility informed (R#1)’s representative and the Department. On April 27, 2026, during an interview with the Executive Director (A#1), he stated that the facility ensures staff follow mandated reporting requirements through online training and in-service trainings provided as needed. (A#1) further stated that the facility reported incidents involving (R#1) to the resident’s representatives and that a copy of the LIC 624 was provided, along with documentation in the notes indicating when the responsible party was informed. On 4/27/2026, the Department could not speak with (R#1) as they no longer reside at the facility. The Department attempted to contact (R#1) using the phone number on file; however, the Department could not reach them. On April 27, 2026, during interviews with residents in care (R#2 through R#9), (8) out of (9) residents stated that when something changes with their health, staff talk to them or let them know if they are informing anyone about it. in addition, residents also stated that if they tell staff they are not feeling well or need help, staff follow up with them or notify someone else as needed. Evaluation Report continues LIC 9099-C On April 27, 2026, during interviews with facility staff (S#1 through S#4), (4) out of (4) staff stated that the facility’s procedures for reporting changes in condition, incidents, or unusual observations begin with the caregiver identifying the concern and initiating an alert. Staff stated that after an alert is initiated, they notify the party responsible and the resident’s physician and then follow any instructions provided by the physician. In addition, (4) out of (4) Staff further stated that when they report a concern or change in a resident’s condition, the information is communicated to the appropriate individuals by updating the resident’s care plan and notifying the resident’s family, such as when a resident sustains a fall. During this investigation, the Department did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Sean Taghizadeh/Executive Director.