complaint·February 29, 2024

The investigation revealed the following: Regarding the allegation: " Resident sustained fractures while in care". It has been alleged that a resident (R1) fell while in care at the facility resulting in a broken (right) hip. IB’s interviews and record reviews revealed the following: On 02/08/2023, during R1’s admission at the facility, R1 walked without assistance and was not known to be a major fall risk. It was recommended that R1 use a walker for slightly unsteady gait and be supervised while walking. On 2/17/2023 R1 had a witnessed fall while ambulating at the facility and was sent to the hospital for assessment, R1 sustained a fracture due to osteoporosis and underwent hip pinning. On 3/06/2023, R1 returned to the facility after receiving physical therapy. Interviews revealed that R1 was not reassessed, despite having had a recent hip fracture and walking with a limp. S3 indicated that had R1 been reassessed, S3 also indicated that the facility would have requested “all the protective things” R1 would need. The facility moved R1 to a different memory care unit and placed R1 on Karemore Hospice on 3/16/2023. Despite these added services, R1 continued attempting to get out of bed without assistance and sustained unwitnessed falls in R1’s facility apartment on 5/14/2023 and 6/03/2023. In response, the facility staff placed pillows next to R1 and engaged the half bed rail to restrain future falls, but R1 was again not reassessed and R1’s responsible person was not notified of the falls. In addition, R1 continued ambulating without a cane and sometimes without supervision. It does not appear the facility requested safety equipment or other protective measures, aside from medication adjustment, and the facility did not provide sustained increased supervision despite claims to the contrary. Two days after R1 expressed pain following her fall on 6/03/2023, R1 sustained a minimally displaced left femoral neck fracture. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC 9099D. Regarding the allegation: "Resident sustained multiple falls while in care". IB’s investigation revealed the following: On 2/17/2023 R1 had a witnessed fall while ambulating at the facility and was sent to the hospital for assessment, R1 sustained a fracture and underwent hip pinning. On 3/06/2023, R1 returned to the facility after receiving physical therapy. Interviews revealed that R1 was not reassessed despite having had a recent hip fracture and walking with a limp. Due to changes in their medical condition, R1 continued attempting to get out of bed without assistance and sustained unwitnessed falls in R1’s facility apartment on 5/14/2023 and 6/03/2023. R1 continued ambulating without a cane and sometimes without supervision. The facility did not request safety equipment or implement protective measures, aside from medication adjustment. Report Continues, see LIC9099C Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC 9099D. At this time, an enhanced 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. A copy of this report and appeals rights were provided to Peggy Clark, Administrator. The investigation revealed the following: Regarding the allegation: "Resident sustained injuries while in care". Interviews and record reviews revealed that the contusion to R1’s right eye and forehead were sustained when R1 accidentally struck their bed rail due to agitation, as caregivers attempted to change R1’s incontinence briefs. Staff stated that R1 deliberately banged their head on the walls. R1 often required up to three caregivers to change their incontinence briefs due to R1’s high combativeness. On the early morning hours of 6/02/2023, while R1 was in bed, an overnight shift staff found R1 with blood on their mouth and teeth. Staff denied R1 sustained an unwitnessed fall. It is important to note that the caregiver moved R1’s legs up and placed pillows next to their body to keep R1 from getting out of bed. It is also important to note, for level of care purposes, that R1 had previously, at times, gotten out of bed and wandered about the facility. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. An exit interview was conducted with Peggy Clark, Administrator, and a copy of this report was provided to Peggy Clark, Administrator.