Complaint·August 11, 2025

Continued from LIC9099... Based on an interview with Administrator/Licensee it was revealed that staff 1 (S1) changed R1 and put the rails up to step away to throw the garbage away from the changing R1 when S1 heard a thump. Additionally, based on an incident report dated 10/11/2024 and received by the Department on 10/16/2024, It was revealed that S1 also stepped away to answer the front door to the facility during the time when the thump was heard by S1. LPA attempted to contact S1 on 04/16/2025, 07/30/2025, and 08/08/2025 but was unsuccessful. Per interview conducted with R1’s responsible party, R1’s husband ordered the hospital bed, which came with full bed rails, prior to the 10/11/2024 incident. LPA spoke with the Hospice Nurse on 08/08/2025 and received emailed transcribed notes from R1’s Hospice file which state that R1 was admitted to Hospice services on 10/13/2024 and a Hospice nurse reported observing the bed rails broken. Additionally, the Hospice notes indicate that R1’s family refused the Hospice ordered bed with half rails. Based on an interview with Staff 2 (S2) on 08/08/2025, facility staff are trained to prepare briefs and items for incontinent care prior performing incontinent care, stay with the resident until done, reposition the resident on their back and put the bedrails up before walking away. Based on further record review, it was revealed on R1’s hospital discharge summary dated 10/13/2024 that as the result of this above-mentioned fall on 10/11/2024, R1 sustained a right nasal bone fracture, a frontal scalp hematoma, bruising of the central forehead, and a small superficial abrasion to the inner left nare. Subsequently, on 04/11/2025, the Department received said complaint #21-AS-20250411091753 which indicated that R1 sustained a second injury on 04/06/2025. During the course of an interview with Administrator/Licensee, it was revealed that while performing incontinent care, S1 rolled R1 resulting in R1’s head coming in contact with the bedside table causing injury and bruising to R1’s upper right eye area as captured in photos taken by LPA on 04/16/2025, (see LIC9099D). An immediate civil penalty in the amount of $500 if being issued during today's visit, (see LIC421IM). Based on a death report received by the Department on 05/15/2025, R1 passed away on 05/07/2025 on Hospice care. Based on interviews conducted and records obtained, the allegation that the facility Staff caused injuries to a resident while in care is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Continued on LIC9099C... Continued from LIC9099C... Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). The licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f). Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents. Appeal rights provided.