complaint·November 30, 2023

R1 was admitted into the facility on 2/1/23. Throughout R1’s stay at the facility multiple staff interviewed observed R1 wandering throughout the facility and had to be redirected, 5 out of 7 staff observed R1 dancing to music in her room. The remaining 2 staff members had no direct knowledge of R1’s initial demeanor. R1’s roommate indicated R1 was up all hours of the night. R1’s roommate stated that R1 would pace back and forth and would go through roommate’s dresser and remove roommates’ clothes. Based on R1’s physician’s report (LIC 602) dated 5/19/2022, R1’s primary diagnosis is dementia with behavioral disturbances and is noted to have aggressive behaviors with sundowning and was confused and disoriented. On 02/6/2023 R1s family visited R1 for the first time since moving in, and they found R1 in a wheelchair and was told by staff that R1 could not stand for long period of time. It was reported by staff that R1 was asked if they had fallen and R1 stated “no”. R1 began to complain of pain when assessed by staff and responsible party when left hip was touched. It was noted R1 was sent to UCI Hospital at 10:40am where they were diagnosed with a fractured pelvis. It was noted by staff in Services Notes on 02/05/2023 at 7am that R1 complained of pelvic, left leg and lower back pain. Based on Service Notes, staff noted R1 was placed in a wheelchair and 911 was not called. It was reported family was not notified until the incident on 02/06/2023. Per California Assisted Living Waiver Individual Service Plan (ALW ISP) dated 8/18/22 R1 requires reinforcement of safety precautions due to being a fall risk and requires assistance with mobility/ambulation. Based on ALW ISP R1 has a history of behaviors due to Alzheimer’s, R1 has a history of wandering behaviors. Based on hospital intake paperwork dated 02/06/2023 there was noted bruising on R1’s left hip and pelvis region. Per review of R1’s Admission Agreement dated 02/01/2023, it was noted that R1 would need assistance with dressing, reminders for eating, toileting, bathing, and grooming. Based on service notes R1 was noted to be placed in a wheelchair on 02/05/2023 at 7 am which would mean the resident was presenting with pain for at least 24 hours prior to be taken to the hospital. A civil penalty is pending determination, per H&S Code Section 1569.49(e). Based on the preponderance of evidence through record review and interviews the allegation Lack of care and supervision from the facility's staff resulted in untimely medical attention for resident who sustained injuries. is SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8 and civil penalties assessed. An exit interview was conducted and a copy of this report and appeal rights was provided to the Administrator. It was reported by Administrator Melinda Flores that she suggests as a best practices to families to allow time for the resident to acclimate to the facility prior to visiting in person and not as instructions or rule. Based on interviews with R1’s family they followed the administrator’s advice. Based on R1’s physician’s report (LIC 602) dated 5/19/2022, R1’s primary diagnosis is dementia with behavioral disturbances. It was reported by facility that on 2/6/2023 R1s family visited R1 for the first time since moving in, and they found R1 in a wheelchair and was told by staff that R1 could not stand for long period of time. R1 was asked if they had fallen and R1 stated “no”. R1 began to complain of pain when assessed by staff and responsible party when left hip was touched. R1 was sent to UCI Hospital where they was diagnosed with a fractured pelvis. It was noted by staff in Services Notes on 02/05/2023 at 7am that R1 complained of pelvic, left leg and lower back pain. R1 was placed in a wheelchair and 911 was not called. It was reported family was notified on 02/06/2023, when the administrator was made aware of the issue. Based on the preponderance of evidence through interviews and records reviewed the allegations that Facility restricted a resident's ability to receive visitors and Facility failed to report a serious incident involving a resident to the Responsible Party are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided.