complaint·September 18, 2025

The investigation revealed the following: Regarding the allegation: “Staff did not provide adequate supervision, resulting in the resident falling and sustaining a fracture.” Records reviewed indicate the following: The Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. The Facility Service Plan (dated 09/06/2024) notes that R1 wanders throughout the building and into other residents’ rooms. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. On 11/05/2024, the Specialty Hospice Care nurse instructed facility staff to assist R1 and not leave R1 unattended due to declining health and generalized body weakness. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. On 01/14/2025, R1 had an unwitnessed fall and was found on the floor near R1’s room, complaining of hip pain. On 01/15/2025, R1 again complained of right hip pain and was transported to the hospital. St. Mary’s Hospital medical records (dated 01/15/2025) confirm that R1 was diagnosed with a right femoral fracture. Interviews indicate the following: Witness W1 stated that R1 was a fall risk and required supervision while ambulating with a walker. Staff members S1 through S13 consistently indicated that R1 was a fall risk and required supervision. S1 reported that on 01/14/2025, S1 and S2 were supervising R1 and other residents in the dining room. However, both staff members left the dining room to respond to an unexpected death in another resident’s room, leaving R1 unsupervised for approximately 20 minutes. During this time, R1 wandered away and had an unwitnessed fall in another resident’s room. Based on the records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation that “staff did not provide adequate supervision, Regarding the Allegation: “ Staff Did Not Seek Medical Attention for Resident.” This complaint alleged that staff failed to seek timely medical attention for a resident who was in pain after an unwitnessed fall. Records reviewed indicate the following: Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. The incident reports dated 01/14/2025 and 01/15/2025 show that on 01/14/2025, R1 was found on the floor following an unwitnessed fall. On 01/15/2025, R1 complained of pain in the right hip. The medical report from St. Mary Medical Center indicates that R1 had fallen on 01/14/2025 and complained of right hip pain. On 01/15/2025, R1 was transported to the hospital and diagnosed with a right femoral fracture. Interviews revealed the following: Staff members S1 through S13 confirmed that R1 experienced an unwitnessed fall on 01/14/2025 and complained of right hip pain. Medtech Jordan Morales and caregiver Marie Reyes recognized that R1 was experiencing pain in the right hip/leg but did not notify the hospice agency or R1’s daughter/POA at the time. Based on observations and interviews conducted by CCLD staff, as well as the records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that “Staff did not seek medical attention for the resident” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed, please see LIC421IM. At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, and plans of corrections were developed and a copy of this report and appeals rights were provided to Administrator Manager Joel Niblett (S1). The investigation consisted of the following: Regarding the Allegation: “Staff did not prevent residents from developing a UTI while in care.” This complaint alleged that staff failed to provide residents with adequate assistance for their incontinent needs, resulting in Resident 1 (R1) developing two urinary tract infections (UTIs) while in care. Records reviewed indicate the following: At Specialty Hospice Care, R1 has a history of falls and a recent right hip fracture. The Physician Report (dated 10/31/2024) lists the primary diagnosis as non-ambulatory and the secondary diagnosis as urinary tract infection (UTI). It also notes bladder and bowel impairments and states that R1 requires assistance with bathing and toileting. St. Mary’s Hospital records (dated 01/15/2025) indicate that, multiple UTIs in the past, which were resolved with antibiotics. Interviews indicate the following : 9 out of 9 staff members denied the allegation. R1 could not be interviewed, as R1 no longer resides at the facility. 9 out of 12 residents denied the allegation. Based on the records reviewed and interviews conducted, the preponderance of evidence standard has not been met. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that "Staff did not prevent resident from developing a UTI while in care" is found to be UNSUBSTANTIATED . An exit interview was conducted, and a copy of this report was provided to Administrator Manager Joel Niblett (S1).