complaint·May 30, 2025

Allegation – Due to staff neglect, resident sustained a serious injury. It is alleged that a caregiver closed the bathroom door while Resident #1’s (R1) hand was in the doorway on 2/21/2024. R1 sustained a serious injury to the right middle finger, resulting in part of the finger getting amputated. LPA interviewed the administrator, who acknowledged that the incident occurred at the facility. Administrator Lin stated that Staff #1 accidentally closed the bathroom door while the resident’s hand was placed on the edge of the door. Staff did not see the hand and closed it, causing injury to the finger. The administrator stated that all the care staff were provided a training immediately after the incident to prevent another accident from occurring. LPA Chan interviewed staff members who indicated that they are careful when handling residents. They ensure that their hands and feet are positioned so that they cannot be injured. Staff stated they try their best to make sure residents are safe. Staff #1 (S1) was interviewed and stated that the incident was accidental and did not see R1’s hand at the door. LPA reviewed R1’s hospital record dated 2/22/2024, and it indicated that R1 was to proceed with surgery to partially amputate the 3 rd digit of the right finger. LPA interviewed 8 residents today. All the residents stated that the staff had not caused injury to them. They think the staff are attentive and well trained. According to the information gathered, staff did not carefully check to make sure the resident’s hand was not in the doorway. Although the incident was accidental, R1 sustained a serious injury that required surgery and partial amputation of the finger. Based on interviews conducted and record 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 LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM*** An exit interview was held. A copy of this report, LIC421IM, and appeal rights were given to licensee Amber Branconier.