complaint·September 19, 2025

It was alleged that due to lack of care and supervision, the facility not allowing R1’s family member to provide extra care, and the facility not assisting R1 with their walker, R1 sustained two falls in early September 2025, one of which resulted in a head injury and hospitalization. LPA inspected the facility, conducted health and safety checks on R1 and other residents, and observed no health and safety issues. LPA interviewed R1 who was unable to provide information regarding this allegation. LPA’s observations of staff ensuring R1 had access to and made use of their walker, as well as LPA’s interview with R1’s family member, did not corroborate that the facility did not assist R1 with their walker. Interviews with PA, facility staff, and R1’s family member revealed that while R1’s family member has a history of providing extra care for R1, during a COVID-19 outbreak in early September 2025, R1’s family member was either strongly encouraged or ordered not to visit with R1 due to COVID-19 precautions, R1’s family member stopped visiting R1 to provide extra care, and during R1’s family member’s absence, R1 suffered a fall resulting in hospitalization. However, regardless of whether R1’s family member was present to provide additional care, it was the facility’s responsibility to provide care and supervision to R1 in light of R1’s fall risk. LPA reviewed R1’s Care Plan which states that R1 is a fall risk and R1’s Care Notes which document previous falls on July 28, 2025, June 14, 2025, and May 19, 2025. Per R1’s Care Notes, R1 tested positive for COVID-19 on September 8, 2025 and interviews with staff revealed that R1’s COVID-19 infection caused R1 to grow increasingly weak. Per R1’s Care Notes, R1 suffered two falls on September 10, 2025, the second of which resulted in hospitalization. LPA reviewed R1’s Medical Records which show that R1 was hospitalized on September 10, 2025 through September 13, 2025 with a primary diagnosis of generalized weakness. Despite R1 being a fall risk with a history of falls and now having increased weakness due to COVID-19, the facility did not provide additional care and supervision to address R1’s increased fall risk resulting in two falls in one day. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that the facility did not notify R1’s responsible party of R1’s falls in early September 2025. LPA interviewed facility staff who denied the allegation, stating that R1’s family member was always notified of incidents involving R1. LPA interviewed R1’s family member who indicated they were made aware of R1’s falls. LPA reviewed R1’s Care Notes which indicate R1’s family member was notified of R1’s recent falls. LPA interviewed one witness who stated that one of R1’s falls was reported after R1 was already at the hospital which did not allow R1’s family to accompany R1 to the hospital. However, based on R1’s Care Notes, R1 was bleeding and 911 was necessary, meaning the first priority for facility staff would be to ensure R1 was on the way to the hospital. While R1’s family member may have been notified after R1 was already at the hospital, the information is conflicting regarding whether the facility should have notified R1’s family earlier. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. It was alleged that multiple residents are not having their briefs changed on a regular basis. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed PA and facility staff who denied the allegation. LPA interviewed R1’s family who did not corroborate any incontinence issues with R1 or other residents. LPA reviewed R1’s Care Schedule for September 2025 which shows staff documenting incontinence care for R1. LPA interviewed five residents who wear diapers and did not obtain information corroborating the allegation. The information obtained did not corroborate the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.