Complaint·October 21, 2025

Personal Rights: Staff left resident unsupervised resulting in an injury. During IBs investigation, it was discovered that on 01/01/25, R-1 experienced a fall at the facility while in the bathroom. It was revealed that R-1 is legally blind. R-1 was initially escorted to the bathroom by S-2 who then momentarily left R-1 in the bathroom while S-2 tended to another resident. S-1 was also present at the facility at that time. Staff interviews revealed that R-1 was equipped with a pendant around R-1’s neck which allows for R-1 to notify staff when R-1 needs assistance. Staff interviews revealed that at the time of the incident, R-1 pressed their pendant alerting them R-1 was done in the bathroom and needed assistance. Interviewed staff indicated they were both tending to other resident at that time and could not assist R-1 in the bathroom right away. During IBs investigation, S-1 also acknowledged that S-1 instructed S-2 to wait because, in the past when R-1 would push the pendant requesting assistance R-1 would not quite be ready. By the time S-2 proceeded to the bathroom to assist R-1, R-1 was discovered laying on the bathroom floor and had already put their diaper on. Interviewed staff indicated they observed an injury to R-1’s left eye as a result of the fall. Per hospital records obtained, as a result of R-1’s fall, R-1 sustained an “impacted femoral neck fracture of the right hip” which required surgery and had a laceration of the left eye cornea. Interviews and documentation corroborate this allegation. Deficiency cited. Refer to LIC 9099D. Due to the seriousness of R-1’s injuries, an immediate Civil Penalty of $500.00 is being issued during today’s visit. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . An exit interview was conducted. A copy of this report and appeals rights were provided to Maria Isabel Tangonan. Personal Rights: Staff did not seek timely medical care for resident in care. During IBs investigation, it was discovered that on 01/01/25, staff called the Administrator/S-3 and informed S-3 of R-1’s fall. Per staff interviews, staff notified S-3 of R-1’s fall within “minutes” of the incident. Per interviews, S-3 contacted R-1’s family member and hospice agency and informed them of R-1’s fall. Staff interviews revealed that staff did not call 911 at that time as R-1 was receiving hospice services (the protocol is to contact the hospice agency prior to calling 911 as hospice services may be interrupted when calling 911). Per interviews, R-1’s family member and hospice agency nurse arrived to this facility within approximately 30 minutes to assess R-1. R-1’s family member decided to take R-1 to the hospital for further evaluation. Interviews do not corroborate this allegation. Although the allegation(s) 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 was conducted and a copy of this report and appeal rights were provided to Maria Isabel Tangonan