Complaint·December 16, 2025

The facility’s Appraisal and Needs and Services Plan dated May 18, 2023, contained only general instructions for redirection with ADLs and noted R1 “walks very fast at times.” It did not include individualized plan, instructions, directives or a defined supervision plan to ensure adequate supervision or preventative fall strategies. Between October 2023 and April 2025, R1 sustained at least nine documented falls. The earliest known incident occurred on October 29, 2023, when R1 fell while attempting to transfer from their bed to wheelchair per Vitas Hospice records. R1 was assessed by Vitas Hospice on November 2, 2023, and documented to have a skin tear to the left elbow. The facility had no records documenting the fall, assessing the R1 and discovering and treating the tear. Ten days later R1 sustained a second fall on November 8, 2023, and complained of left hip pain. R1 was transferred to Kaiser Hospital and diagnosed with left intertrochanteric femur fracture and underwent surgical repair the following day. R1 was later transferred to South Coast Post Acute Care for Rehabilitation. The facility’s internal self-report reflects the fall entry was not documented until November 29, 2023. Despite the seriousness of the incident, no significant changes were made to R1’s supervision schedule or care plan. On February 19, 2024, hospice documented that R1 was a high fall risk and uncooperative with transfers. On June 27, 2024, Hospice again documented that R1 was a high fall risk. On July 08, 2024, R1 sustained another fall as documented by Vitas Hospice. No injuries were noted on the report. Hospice records documented R1 sustained a follow up fall on August 11, 2024, and did not sustain any serious injuries. On December 17, 2024, R1 complained of knee pain and swelling which was reported by the facility Med Tech to Vitas Hospice nurse. The visiting nurse prescribed Tylenol for R1’s pain and instructions to staff to monitor the swelling and contract hospice if needed. On December 26, 2024, R1 was observed to still have left knee swelling by the hospice doctor, however, facility staff denied R1 sustaining any fall. A subsequent X-ray completed on December 27, 2024, by Pacific Coast Mobile Radiology confirmed a complete transverse fracture of the distal left femur. Facility documentation stated that R1 kicked the bed railing. Despite the seriousness of the incident, no significant changes were made to R1’s supervision schedule or care plan. The facility did not re-appraise R1. R1’s Physician’s Report was updated on March 13, 2024, and March 6, 2025, and reaffirmed that R1 remained non-ambulatory and dependent for all transfers. {***CONTINUE 9099C2} On March 10, 2025, R1’s appraisal was updated and notated that they were a fall risk and was sent to the hospital for behavioral management. The Needs and Services Plan documented that R1 constantly attempted to get up and walk unassisted due to confusion yet still lacked specific plan, instructions or directives regarding supervision frequency or staffing interventions. On March 20, 2025, R1 sustained an unwitnessed fall and was found by facility staff on the floor with no visible injuries noted. On April 16, 2025, R1 was observed to have a bruise to their left forehead. Two days later, hospice held a meeting with the facility staff and documented that a six-bed facility may be more appropriate to meet R1’s increased needs. Later that night, R1 sustained an unwitnessed fall around 8 PM. Hospice records note that the facility refused a visit upon the fall and requested hospice to visit the following day. Interviews conducted revealed that the Administrator (AD) stated staff were expected to conduct resident checks every fifteen to thirty minutes during the day and every fifteen minutes at night. However, interviews with two of two caregivers indicated that checks were typically conducted approximately every two hours. Hospice records documented repeated recommendations for increased supervision, and when they attempted to discuss the matter with the Administrator (AD), AD replied that she was “too busy.” Facility documentation reflected that bed rails, bed alarms, and floor mats were in place. However, multiple hospice notes indicated delayed or inconsistent staff response, demonstrating that these measures were insufficient to prevent repeated falls and injuries. Based on review of hospice medical records, hospital discharge summaries, facility incident reports, and interviews with staff and hospice personnel, the facility failed to modify its supervision plan or implement effective interventions despite repeated falls and serious injuries to R1 over an 18-month period. The preponderance of evidence has been met and the allegation Lack of supervision resulting in resident sustaining multiple falls is deemed to be SUBSTANTIATED. The following is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). An exit interview was conducted, and copies of this report, LIC 9099-D, Appeal Rights, Immediate Civil Penalty Assessment, and LIC 811 (Confidential Names) were provided to AD, Weiner Elena , at the conclusion of the visit.