complaint·November 13, 2024

Continued LIC9099-C page 2 The department requested copies of the following documents: Personnel Report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Medication Logs, Consent Forms, Replacement Appraisal Information, Appraisal and Needs Service Plan, Resident Progress Notes, Long Beach Memorial Hospital Medical Records, Windsor Convalescent Hospital Medical Records, Long Beach Police Department Call Log, Special Incident Reports, In-Service Training, Training on Reporting Dependent Adult and Elder Abuse, and any Ongoing Training. Allegation: Lack of supervision resulted in the resident falling and sustaining multiple injuries The department interviewed staff members 1-6 (S1-S6), residents 1-13 (R1-13), and witnesses 1-4 (W1-W4). Based on files, and interviews, there was insufficient evidence to prove that the facility was responsible for neglect or lack of care and supervision, leading to the resident's unwitnessed fall at the facility on June 22, 2024, which resulted in multiple injuries. According to the resident's medical records from Long Beach Memorial Hospital, the resident sustained a stroke, which may have contributed to the unwitnessed fall. Staff, the resident's physician, and witness statements indicated no change in the resident condition that would have raised any concern for the resident to fall. The resident was documented as ambulatory and able to dance during a replacement assessment on May 16, 2024. The resident's physician confirmed that upon discharge from Windsor Convalescent Hospital on May 25, 20024, the resident was ambulatory and walked with ease. The physician added that the resident frequently danced while at the hospital. Investigation revealed the following: Based on the evidence received from the medical records, staff, resident's physician, the residents, and witnesses there was sufficient staff on duty in the memory care unit at the time of the fall. Staff immediately responded to the resident's room upon hearing a loud sound, provided assistance, and called 911 promptly. The staff took all necessary precautions to assist the resident. The staff could not have prevented the resident from falling. The allegation of neglect lack of care and supervision leading to the resident falling and sustaining multiple injuries was unsubstantiated. See the continued LIC9099-C page 3. Continued LIC9099-C page 3 Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-Cs, was provided to the Administrator Peggy Clark. There were no deficiencies cited. An exit interview was conducted