Complaint·February 6, 2026

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff caused injuries to a resident. It is alleged that staff caused injuries to Resident #1 (R1). Reports suggest that due to staff negligence, the staff member caused (R1) to fall out of the wheelchair and sustained head, knee, and fracture injuries. According to the report, (R1) was being pushed in a wheelchair by staff who took a fast turn, causing (R1) to fall out of the wheelchair. The incident occurred at City View on January 15, 2026, requiring emergency hospitalization. No additional details regarding this allegation have been provided. On February 06, 2026, between 10:00 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of five (5) cannot corroborate this claim of (R1’s) fall was due to staff negligence in care. (S1) clarified that the fall did not occur due to any negligence on (S1's) part. On January 15, 2026, (R1) was being wheeled into the activity room when (R1) leaned forward and subsequently slipped out of the wheelchair before (S1) had the opportunity to assist. (S1) confirmed that (S1) had made a turn to navigate around oncoming obstacles, noting that the turn was executed carefully and was not a sharp or reckless turn. (S1) reported that (R1) received immediate medical assistance for a head injury and was uncertain about any injuries to the lower body at that time since (R1) was fully clothed. (S1) through (S5) confirmed (S1)'s account of the incident and were unaware that (R1) had sustained additional injuries to the knee, including a fracture, until the hospital provided this information. (S2-S3) noted that (R1) is on medications that increase sensitivity and the risk of injury due to the prescribed medication. (S2-S3) verified that (R1) had not been assessed as a fall risk and had never experienced a fall while at the facility. (S1 and S4-S5) verified completion of mandated staff training including fall prevention, proper positioning, back injury prevention, hoyer lift usability, and timely response to call lights. On February 06, 2026, between 10:35 AM and 02:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of ten (10) cannot support this claim. All nine residents require assistive devices and report that staff are careful and attentive when assisting with mobility. Furthermore, none of the nine residents have experienced falls or injuries due to staff negligence or lack of care. Resident #1 (R1) was interviewed, but due to (R1’s) health condition, (R1) was unable to engage in a conversation. (Evaluation Report continues LIC 9099-C) On February 04, 2026, between 11:02 AM and 12:20 PM, the Department interviewed witnesses identified as Witness #1 and Witness #2 (W1-W2). Two (2) out of two (2) witnesses could not corroborate this claim. (W1) is close to (R1) and noted that (R1) sometimes slips out of (R1's) wheelchair. (W1) asked (R1's) doctor about using a seat belt, but the doctor did not approve it. (W1) also mentioned that (R1) takes several medications that can make (R1) less stable and affect (R1's) skin condition, which increases the risk of injuries. (W2) provided extra care services two times a week from November 2025 to January 2026. (W2) said that (R1) was not assessed for fall risk and that there were no falls or injuries during the care. (W2) worked alongside the facility staff and never observed any negligence or neglect in the care provided by the staff. On January 21, 2026, the Department inspected the area of the activity room where the incident occurred and did not observe any health or safety issues. A review of Resident #1 (R1’s) service record included Medical Assessment for Residential Care Facilities for Elderly LIC 602A (dated 006/05/25), Identification and Emergency Information LIC 601 (dated 03/19/18), Face Sheet and Emergency Info (dated 08/21/24) Service Plan (dated 10/12/25), Resident Appraisal LIC 603A (dated 10/27/22), Morse Fall Scale (dated 10/227/22), OC Hospice Care , Inc Record (dated 11/11/25), Unusual Incident Report LIC 624 (dated 01/20/26 & 10/12/25) Facility Progress Report (dated 01/28/26). Further review of Medication Administration Record (dated 12/01/25 – 12/31/25) revealed (38) medications are prescribed, with (19) significantly increasing the risk of falls. Additionally, (2) medications thin the blood, making individuals more prone to injuries (ref: National Institute of Health NIH). Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. 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 is Unsubstantiated . No deficiencies were cited An exit interview was conducted with Marcia McKay, and copies of the reports were provided.