Inspector’s narrative
What the inspector wrote
Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility for the purpose of delivering finding regarding case management conducted on March 07, 2025. LPA Haddadin was greeted by Assistant Executive Director, Sammy Lee who granted access to the facility, at which time the purpose of the visit was explained. On March 03, 2025, the Regional Office received a self-reported unusual incident report from the facility reporting the hospitalization of Resident 1 (R1) resulting in a bone fracture. A case management health and safety visit was then completed on March, 07
th
, 2025. The investigation determined as follows:
A review of facility and medical records established that Resident 1 (R1) has a documented history of Parkinson’s Disease with progressive physical decline, intermittent confusion, and Mild Cognitive Impairment, as reflected in a Physician’s Report dated May 10, 2022. Internal Incident Reports from October of 2024 to February 12, 2025, show that R1 experienced at least eight unwitnessed falls despite existing fall-risk measures developed by the Assisted Living Waiver Program (ALW). A review of R1's Individual Service Plan assessed by the dated February 6, 2025, to August 6, 2025, R1 was identified as having poor safety awareness and being at high risk for falls. A fall mitigation plan had been developed by the ALW and recommended to manage these risks. {***CONTINUE 809C***}
Per review of R1’s file, the facility failed to conduct an appraisal of R1’s needs.
The most recent unwitnessed fall occurred on February 12, 2025, around 10 A.M. Following the fall, facility staff contacted R1’s hospice agency. Hospice agency notes dated February 12, 2025, document that a hospice nurse visited R1 at 1:15 P.M. During the visit, R1 was alert but confused, able to communicate, and reported severe, constant pain in the left arm and shoulder, grimacing with movement. Assessment revealed swelling in the left anterior shoulder, but no visible bruising was present at that time. Although R1 could move and bend the shoulder slowly, it caused significant discomfort. Hospice ordered pain medication for R1 and instructed staff to monitor for worsening pain and to contact hospice if medication was not effective. Photographic evidence from February 14, 2025, depicted significant bruising and edema on R1’s left upper extremity. Facility staff notes on February 14, 2025, at 7:40 p.m. documented a call from MedTech (MT) to the Administrator requesting transfer for hospital evaluation; however, after consulting with R1’s hospice doctor, the decision was made to keep R1 at the facility. Hospice nurse assessed R1 and noted shortness of breath, significant pain, and swelling in the left upper extremity (LUE) and bruising from the shoulder to the elbow. R1 was found lying in bed and was unable to move the left arm, an observed decline from two days earlier, when limited movement was still possible. Pain was reported as severe, consistent with a pain scale of 10/10 with movement. R1 required complete assistance with all activities of daily living (ADLs), including feeding, bathing, dressing, toileting, turning, and mobility. Hospice agency ordered an X-ray and provided new orders for medication and treatment for R1. R1’s family was informed and agreed not to transfer R1 to the hospital, however the R1 was not conserved and had no POA. Even though Hospice agency instructed facility staff to apply an ice pack and monitor changes and report them, the facility staff did not complete any further post-fall monitoring observations or progress notes from February 14 through February 22, 2025. On February 18, 2025, a portable X-Ray was executed and the R1 was diagnosed with an injury at the top of the upper arm bone and a shoulder dislocation. After consulting with an orthopedic doctor, it was decided that a closed reduction could be attempted. (Per Mayo Clinic definition a Closed reduction is a procedure where some gentle maneuvers might help move the shoulder bones back into position.***{CONTINUE 809C***}
Depending on the amount of pain and swelling, a muscle relaxant or sedative or, rarely, a general anesthetic might be given before moving the shoulder bones. When the shoulder bones are back in place, severe pain should improve almost immediately.) R1 was given pain medication, and the reduction was performed. A follow-up X-ray was ordered to confirm successful reduction. By February 21, 2025, a repeat X-ray showed that the shoulder was still dislocated. Plans were made to take R1 to an orthopedic clinic the next day. However, on February 22, 2025, R1 was transferred to the hospital by a family member. Medical record from the Hoag Hospital Emergency Center dated February 22, 2025, listed R1’s diagnoses as a dislocation of the left shoulder joint, a closed fracture of the head of the left humerus, and an acute embolism and thrombosis of the deep vein of the left upper extremity.
Interviews with four staff conducted during the investigation denied any failure to provide adequate supervision or to initiate a timely medical response following the falls of R1; however, the facility’s Internal Incident Report from February 22, 2025, states that R1 complained of severe left arm pain immediately following the fall. Despite this, facility staff notified hospice instead of contacting 911.
Based on the preponderance of evidence, the facility did not provide care and supervision and failed to seek timely medical attention.
The facility is being cited for violating Title 22, Division 6 of the California Code of Regulations. An immediate civil penalty was assessed per LIC421IM. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49. An exit interview was conducted and a copy of this report along with LIC809-D, Appeal Rights, Civil Penalty Assessment -LIC 421 IM and the LIC 811, identifying confidential names were provided.
