complaint·May 23, 2025

Resident sustained fractures due to staff neglect It was alleged that due to neglect/lack of care and supervision resulted in Resident 1 (R1) falling on 01/12/2022 and sustaining two femur fractures. During the course of the investigation LPA interviewed R1, witnesses, and prior Facility Director Heather Myers regarding R1's fall and injury on 1/12/2022 which occurred in their room and was unwitnessed. Witness statement indicated that R1 used their pendant to call for assistance to go to the bathroom. R1 got up on their own when staff did not respond in a timely manner, and R1 fell to the floor breaking both femurs. R1 stated they got out of bed on their own and went to the bathroom using their walker. When R1 was finished on the toilet, they stood up to get their walker and fell to the ground, breaking both of their femurs. R1 stated they could not recall using their pendant to call for staff assistance when they had finished using the toilet, nor when they were on the ground after the fall. R1 stated they screamed for help and staff arrived quickly. LPA reviewed the Unusual Incident/Injury Report related to this incident which states R1 told the Med Tech Staff 1 (S1) that R1 rolled out of their bed injuring their legs. LPA spoke with Heather Myers who was the Facility Director on 1/12/2022. Heather stated that R1 was brought a daybed and R1 would place their ankles under the foot rail. On the evening of 1/12/2022, it is believed R1 broke their legs when rolling out of bed with their ankles caught in the bedrail of the daybed. Heather stated when staff found R1 in their room, they were lying next to their bed still wrapped in their blankets. R1 was assessed by facility staff who immediately called 911 and notified a family member. R1 was transported to the hospital for further evaluation and diagnosed with femur fractures in both legs. S1 does not work at the facility any longer and LPA’s attempts to contact them were unsuccessful. Based on interviews and document review, there was no evidence to corroborate the allegation of neglect by staff resulting in R1's fall and injury. Therefore, the allegation of Neglect/Lack of Care and Supervision of Resident R1 falling on 1/12/2022 and sustaining two femur fractures will be unsubstantiated. **Continued on 9099-C2 page** Resident fell multiple times due to staff neglect Neglect/Lack of Care and Supervision or Resident 1 (R1), falling on 8/6/2023, and sustaining a sprained ankle. On 8/6/2023, Resident 1 (R1) suffered an unwitnessed fall in their bathroom. Witnesses stated that R1 used their pendant to get assistance from bed to go to the bathroom and a staff member responded promptly and transferred R1 from their bed to the toilet. When R1 was done using the toilet, they used their pendant for assistance to get off the toilet and be taken back to bed. R1 waited a long time and when no one responded, R1 got up on their own and fell injuring their ankle. R1 stated they transferred themself from their bed to their wheelchair and got to the bathroom on their own. When R1 was done using the toilet, they used their pendant and emergency pull chain in the bathroom to call for assistance with getting up from the toilet and back to bed. R1's legs started to hurt, so they attempted to get from the toilet to their wheelchair and fell. R1 estimates they were on the bathroom floor for approximately 30 minutes before a staff member found them and assisted them back to bed. R1 stated they were not experiencing any immediate pain and there was no visible injury. R1 said they began to experience pain later in the day, did not notify staff of their pain. R1 stated staff wanted them to be sent to the hospital for evaluation, but R1 refused and wanted to wait and see if it got better on its own. R1 was taken to the hospital a few days later, and R1 was diagnosed with an ankle sprain. LPA requested pendent call logs for this incident to determine the length of time it took staff to respond and was advised that the system is only able to retrieve the previous week of calls. By the time LPA requested them, the logs were no longer available. LPA did review currently accessible call logs dated 9/1/2023 through 9/7/2023 and the majority of the requests were responded to in ten minutes or less. There was no evidence to corroborate the allegation of neglect by staff resulting in R1's fall and injury on 08/06/2023 or 01/12/2022. This allegation is unsubstantiated. **Continued on 9099-C3 page** Unlawful eviction LPA reviewed a letter from the facility to R1’s POA dated September 01, 2023, which states the facility is serving a 30-day eviction notice to R1 based on a recent appraisal which determined that the facility could no longer meet the needs of R1. LPA reviewed an eviction notice dated August 24, 2023, and a Negotiated Risk Assessment for dated August 17, 2023, which states the POA for R1 has been advised that R1 is a high fall risk and the facility feels that R1 needs a higher level of care to avoid any future incidents of falls. R1 will need additional support to try to reduce the risk of falls. R1 may remain in the community until the facility reaches the point where it cannot provide care at all. Alternatives offered and/or attempted to decrease risk, including, but not limited to: Suggested higher level of care to support high fall risk. Attempted: Discussed this and was declined by POA. This allegation is unsubstantiated. Staff did not provide resident's authorized representative with itemization of fee increase LPA reviewed a letter from the facility addressed to R1 which states “Beginning 07/01/2023 your monthly total will be $5050.00 for rent and services. This will include all regular monthly items currently on your account. This notification lists R1’s current monthly charges of $4,410.00 with care charge of $420.00 for a total charge of $4,830.00 per month. Notification also included the proposed new charges of $4,630.00 and care charges of $420.00 for a total of $5,050.00 per month beginning on 07/01/2023. This letter serves as your 60-day written notice, as stated in your Rental Agreement. LPA also reviewed a Resident Statement dated 08/01/2023 for Resident 1 (R1). The statement lists R1’s monthly charge of $4,630.00 and a care charge of $420.00. This allegation is unsubstantiated. **Continued on 9099-C4 page** Facility internet is in disrepair On 09/05/2023 LPA toured the facility and conducted interviews. On that day LPA determined that the internet was working in the facility. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.