complaint·May 20, 2025

Allegation : Questionable Death The details of the complaint alleged S1 wheeled R1 into R1 bed room and left R1 unsupervised for an extended amount of time while R1 had a safety belt attached to R1 wheelchair. During this time, R1 aspirated and died. The department conducted interviews with the Administrator (A1) and Staff #1-8. A-1 Carla Mariano confirmed that R#1 was left in a room unsupervised approximately 1.5 hours with her safety belt on and was found slumped over in her wheelchair unresponsive. 8 out of 8 staff confirmed the allegation occurred. The department conducted records review which revealed R1 was admitted to the facility on 9/4/2021 (Resident Assessment Form, dated 9/4/2021) with primary diagnoses which included hypertension, agitation, generalized muscle weakness, and dementia. R1 was dependent with all ADLs, except assistance with feeding. R1 had motor impairment/paralysis in which R1 was wheelchair bound and unable to maneuver without assistance. R1 required assistance with transfer to and from the bed. R1 was noted with fair physical health status (Physician’s Report, dated 12/14/2022). It was also noted resident had diagnosis of dysphagia (Physician’s Report dated 9/7/2021). Based on the department’s review of R1 record there was no documented evidence a care plan to address the use of safety belt on the wheelchair for R1. Also, there was no care plan to address when and how often resident should be monitored on the wheelchair with R1 safety belt fastened. Lastly, there was no care plan to address resident at risk for aspiration/choking due to diagnosis of dysphagia and or any interventions to prevent resident from injuries related to the use of safety belt. The department reviewed the Death Certificate (dated 2/14/2023) which indicated the immediate cause: Possible aspiration. Based on the interviews conducted and records reviewed S1 failed to properly supervise R1 resulting in the death of R1. Based on records review and interviews, the preponderance of evidence standard has been met; therefore, the allegation of “Questionable Death” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. Regarding the Allegation: Staff did not ensure postural support was used as prescribed. This complaint alleged that staff did not follow doctor’s orders on use of R1 Postural Support (safety belt) which resulted in the resident sliding out of the wheelchair. The department conducted interviews with the Administrator (A1) and Staff #1-8. A1 confirmed the allegation and 8 out of 8 staff confirmed the allegation occurred.. The department received an Unusual Incident/Injury Report from Regency Palms at Long Beach (dated 1/7/2023), indicated: on 1/7/2023 at approx. 11:15 a.m., R1 was observed sliding out of her wheelchair. With no complaints of pain or discomfort. Staff monitored resident and adjust as needed in wheelchair if noted sliding. Records review indicate the following: R1 Physician’s Report (dated 09/27/2021) indicates the safety belt is to keep R1 from sliding or falling from R1's wheelchair. Based on interviews and records reviewed staffed failed to use the postural support as prescribed which resulted in R1 sliding out of her wheelchair. Based on records review and interviews, the preponderance of evidence standard has been met; therefore, the allegation of “Staff did not ensure postural support was used as prescribed.” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. An $500 immediate civil penalty assessed. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e) Serious Death. Exit interview conducted with Administrator and appeal rights provided. Regarding the Allegation: Staff did not secure resident's medication It is alleged that the facility staff do not secure residents medication resulting in medication ( Atorvastatin ) being stolen in December 2022. On 8/30/23 at around 12:04pm The department interviewed Staff and residents. 5 of 5 residents denied they have not had any missing medications nor ever running out of medications. 4 of 4 Staff interviewed deny the allegation and state that medications is ordered from the pharmacy and delivered to the facility. The facility staff sign for medications and take to Medication Room where it is locked and secured. No medications has come up missing. The Department observed the medication Mars records for R1 from April 2022 to Jan 2023. Upon review of the medication record of R#1 ,The Department finds that medication was given to R#1 as prescribed by physician. Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Administrator.