complaint·July 29, 2025

Regarding the allegation, Staff did not prevent resident from being assaulted at the facility resulting in multiple injuries, the investigation is as follows: On November 19, 2024, at or approximately 3:30pm, Staff #1 (S1) and Staff #4 (S4) was called for assistance concerning a scream coming from R1’s room in the memory care unit. A witness, who had heard the scream through the shared wall, observed R2 exiting R1’s room at the time the screaming occurred. R1 was observed on the floor alone with discoloration to the face and reported being punched by a male resident. The medical report dated January 2, 2025 of page 156 diagnosed R1’s injury as a closed traumatic nondisplaced fracture of neck of the left femur as a result of the fall caused by the punch. Based on the review of R2’s records, R2 was admitted to the facility on August 12, 2024. R2 resides in the memory care unit and has a diagnosis of Dementia, confusion/disorientation with sundowning behavior, and was noted not to display any inappropriate or aggressive behaviors per the Physician’s Report dated August 7, 2024. However, there were twelve instances where R2 displayed behaviors prior to the incident occurring on November 19, 2024, all of which were documented on the progress notes with the first incident starting the next day R2 moved in. Examples of incidents include R2 continuously wandering into residents’ rooms, physically assaulting residents and staff (by hitting, grabbing, pushing, and throwing objects) between the period of August 13, 2024 to October 31, 2024. The September 13, 2024 memory care appraisal also documented R2 not exhibiting behaviors and requiring status checks at regular intervals even though there were six documented instances prior to September 13th. Conversely, the service agreement dated September 13, 2024, documented R2 requiring “staff intervention and/or redirection” due to exit seeking and wandering behaviors which contradicts the appraisal. Per the November 2024 caregiver schedule, seven staff were scheduled during the 2pm-10pm shift which was verified per the time cards for November 19, 2024. There were 52 memory care residents registered on November 19, 2024 also confirmed by staff. Based on the interviews, thirteen out of the thirteen staff did not recall the care staff assigned to monitor R1 and R2 on November 19th. Two direct care staff, Staff #2 (S2) and Staff #3 (S3) confirmed conducting checks on R1 at approximately 2pm. The Department requested copy of the care staff assignment for November 19, 2024, to demonstrate adequate staff coverage, however the facility failed to provide requested documents stating that care staff assignments were archived and kept only for 90 days. Out of the thirteen staff, four reported insufficient staffing and indicated that many other staff expressing the need for an additional staff for R2 multiple times prior to the incident. It was reported that facility accepted the wishes of R2’s family not to implement any changes of care, therefore additional staff was not provided. Two staff reported having 5-6 staff on duty during the PM shift on November 19th, however staff expressed challenges caring for R2 with six staff as R2 required constant monitoring. Regarding the allegation, facility did not seek medical attention in a timely manner, the physical assault occurred at or approximately 3:30pm on November 19, 2024. R1 sustained a closed traumatic non-displaced fracture of neck of the left femur as a result of the punch thrown by R2, exacerbated their chronic back pain, developed a new left hip pain, and was hypoxic per page 156 of the hospital medical report. S1 and S4 reported to R1’s room after being informed by a witness who heard the scream coming from R1’s room. S1 and S4 found R1 on the floor visibly upset with discoloration to the face and complained of generalized pain. S1, S4, and Staff #5 (S5) performed a physical assessment on R1 including the upper and lower extremities and observed no visible injuries per staff interviews. The facility record “Outside Agency Documentation” dated November 19, 2024, documented R1 meeting with their social worker for their weekly therapy appointment following the incident from 3:40pm-4:55pm. Prior to the visit, R1 was asked by S3 and the social worker if R1 wanted to reschedule the visit. R1 expressed wanting to proceed with the visit but continued to complain feeling sore from the fall during the meeting. Staff assumed that R1 is “doing okay” at approximately 5:18pm as R1 was eating their dinner and conversing with other residents at their table. However, facility progress notes document that R1 continued to complain of pain, so 911 was called at 6:03pm. It was reported that R1’s representative who had arrived at the facility between 6-7pm had prompted the staff to call 911 because the call had not been made which was aligned with the documentation on the Physician Communication for R1 dated November 20, 2024. The investigation revealed substantial evidence corroborating the need for additional staff for R2 based on the information obtained during the interviews and the increase in behaviors that were documented on the progress notes between August 13th to November 20, 2024. There were twelve documented incidents that occurred prior to November 19th. The need for increased staffing for R2 was critical to ensure the safety and well-being of R2 and other residents and staff. Regarding seeking medical attention in a timely manner, although there were no visible injuries as per interviewed staff, R1 had complained of pain at the time of the physical assessment after the fall. R1 continued to express pain at their weekly therapy appointment and dinner. The physician’s report dated February 21, 2024, documents R1 being able to communicate their needs. Even though R1 had no visible injuries as per interviewed staff and had allegedly refused medical treatment initially, it was imperative that facility sought medical attention considering the nature of the fall and R1’s Dementia diagnosis. R1 did not receive medical attention until 3 hours later after the fall and not before family member prompted the staff to call 911 even though R1 continued to express pain. Therefore, based on the Department’s interviews and the review of records, the preponderance of evidence standard has been met, therefore the following allegations: Staff did not prevent resident from being assaulted at the facility resulting in multiple injuries and Facility did not seek medical attention in a timely manner are deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of California Code of Regulations. Deficiencies are being cited on the attached LIC9099D, and an immediate Civil Penalty (CP) is being assessed. See the attached LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) as per Health & Safety Code 1569.49(f). An exit interview was conducted with Assistant Executive Director Maggie Pantaleon, Shores Program Director Danica Coronel, and North Executive Director Selene Lopez in person and Executive Director Bob Fiorentino by telephone, and a copy of this report including the LIC9099Cs, LIC9099D, LIC421IM, LIC811s, and the appeal rights were provided at the end of the visit.