Complaint·April 25, 2024

analyst (LPA) Lizeth Villegas conducted a subsequent visit regarding the above allegation. LPA met with Executive director Mendy Ginsburg. LPA Villegas obtained copies R1's complete file, S1's employee file, S1's training verification, menus for the month of June, July and August 2022, a copy of Food handlers’ certificate, and a list of all incontinent residents and Incontinence Care Procedures. On 08/04/23 LPA Villegas interviewed Residents # 2-8 (R2-R8), Executive Director (ED), and staff #2-5 (S2-S5). On 03/22/24 LPA Villegas interviewed support staff #1-3 (SS1-SS3). On 04/25/24 LPA Villegas interviewed R9-R12. Allegation: Resident sustained a fracture while in care It is alleged on 7/28/2022, Caregiver #1 assisted Resident #1 with transferring from R1 wheelchair to the toilet so that R1 could use the restroom. Once CG1 placed R1 on the toilet R1 fell forward which resulted in R1 sustaining bruising and a fracture. As apart of the investigation IB investigator conducted a review of R1 file which revealed R1 was admitted to the facility on 6/6/2022 and was admitted in the memory care unit based on R1 medical diagnosis. According to R1 Physicians Report dated 5/21/2022 indicates R1 required full assistance with toileting. Review of R1 Wellness Assessment dated 6/5/2022 revealed R1 required weight bearing assistance with to get in and out of bed, chair, car and etc. The file review also revealed R1 was a fall risk due to R1 falls that occurred prior to R1 admission to the facility. On 09/21/2022, IB investigator interviewed Caregiver #1-#4 (CG1-4) regarding the allegation and 1 of 4 caregivers interviewed denied working the day of the incident and denied witnessing the incident; 3 of 4 caregivers interviewed Were working during the incident and confirmed being aware R1 had an incident in the bathroom. 3 of 4 caregivers interviewed stated they usually use 2 caregivers to transfer and assist residents that could not assist with the transfers from Wheelchair, bed or toilet. CG #1 was interviewed and stated CG1 witness the incident and stated she took R1 to use the toilet by herself because the other Caregiver was assisting another resident and R1 requested to use the restroom. CG1 stated she transferred R1 from wheelchair to the toilet and when CG1 attempted to assist R1 with R1 pants the resident leaned forward to get toilet paper and fell into the wall. CG1 asked R1 if R1 was ok and R1 replied yes and CG1 took R1 to the bed. Allegation: Facility staff failed to seek timely medical attention. It is alleged on 7/28/2022, Caregiver #1 assisted Resident #1 with transferring from R1 wheelchair to the toilet so that R1 could use the restroom. Once CG1 placed R1 on the toilet R1 fell forward which resulted in R1 hitting R1 head and falling. CG1 did not seek any medical attention with the knowledge R1 had hit R1 head and had an injury to the face. As apart of the investigation IB investigator conducted a review of R1 file which revealed R1 was admitted to the facility on 6/6/2022 and was admitted in the memory care unit based on R1 medical diagnosis of Dementia. According to R1 Physicians Report dated 5/21/2022 indicates R1 required full assistance with toileting. Review of R1 Wellness Assessment dated 6/5/2022 revealed R1 required weight bearing assistance with to get in and out of bed, chair, car and etc. The file review also revealed R1 was a fall risk due to R1 falls that occurred prior to R1 admission to the facility. On 09/21/2022, IB investigator interviewed Caregiver #1-#4 (CG1-4) regarding the allegation and 1 of 4 caregivers interviewed denied working the day of the incident and denied witnessing the incident; 3 of 4 caregivers interviewed Were working during the incident and confirmed being aware R1 had an incident in the bathroom. 3 of 4 caregivers interviewed stated they usually use 2 caregivers to transfer and assist residents that could not assist with the transfers from Wheelchair, bed or toilet. CG #1 was interviewed and stated CG1 witness the incident and stated she took R1 to use the toilet by herself because the other Caregiver was assisting another resident and R1 requested to use the restroom. CG1 stated she transferred R1 from wheelchair to the toilet and when CG1 attempted to assist R1 with R1 pants the resident leaned forward to get toilet paper and fell into the wall. CG1 asked R1 if R1 was ok and R1 replied yes and CG1 took R1 to the bed. IB investigator interviewed Witness #1 (W1) and W1 stated when W1 arrived to the facility during dinner on 7/29/2022 W1 asked staff to take R1 to the emergency room due to severe bruising to the face. Based on interviews conducted and records reviewed staff failed to ensure R1 received timely medical attention after a fall in which R1 hit R1 and the next day once bruising became more prominent staff still did not seek medical attention until urged to do so by R1 responsible party. Based on Investigators interviews which were conducted with Program Manager, residents, staff and records review, 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) and Chapter (8) are being cited on the attached LIC9099-D. 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.” Civil Penalties Assessed in the amount of 500 dollars. Exit interview conducted, appeal rights were discussed, and a copy of this report was provided. complete file, S1's employee file, S1's training verification, menus for the month of June, July and August 2022, a copy of Food handlers’ certificate, and a list of all incontinent residents and Incontinence Care Procedures. On 08/04/23 LPA Villegas interviewed Residents # 2-8 (R2-R8), Executive Director (ED), and staff #2-5 (S2-S5). On 03/22/24 LPA Villegas interviewed support staff #1-3 (SS1-SS3). On 04/25/24 LPA Villegas interviewed R9-R12. Allegation: Food is not of good quality It is alleged that the food being served at the facility is not of good quality. On 08/04/23 LPA Villegas interviewed ED regarding the above allegation, Ed denied the allegation above. Per ED the facility serves different types of food daily, the menu is reviewed by dietician monthly and dietary meetings are held once a month. On 08/04/23 LPA Villegas interviewed S2-S5 regarding the above allegation, 3 of 4 staff interviewed denied the allegation above. 1 of 4 staff interviewed reported being unaware of kitchen protocols. On 08/04/23 interviewed Residents # 2-8 (R2-R8) regarding the above allegation, 7 of 7 residents interviewed denied the allegation above and reported they are accommodated with food substitutions when needed. LPA was unable to interview R1 as R1 is no longer receiving care at the facility. Allegation: Facility staff failed to meet resident incontinence needs It is being alleged that staff leave residents in soiled diapers. On 08/04/23 LPA Villegas interviewed ED regarding the above allegation, ED denied the allegation above and stated residents are being checked on every 2 hours. Per ED the number of times residents are being changed depends on their level of care. On 08/04/23 LPA Villegas interviewed S2-S5 regarding the above allegation, 4 of 4 staff interviewed reported residents are changes multiple times a day. 08/04/23 interviewed Residents # 2-8 (R2-R8) regarding the above allegation, 7 of 7 residents interviewed reporting not requiring assistance with incontinence needs. On 04/25/24 LPA Villegas interviewed R9-R12, 4 of 4 residents interviewed reported staff are assisting with incontinence needs every 2 hours. 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, and a copy of this report was provided.