complaint·October 21, 2022

Lack of supervision led to resident injuries. Per R1s Needs and Services Plan, R1 required regular checks (every two hours) during the nighttime or when R1s sensors would go off. R1 required full assistance with transfers. Per R1’s medical records, a Computed Tomography Scan (CT) was performed on 3/22/2022. The scan revealed that R1 had several areas of old vertebral compression fractures, old rib fractures, and findings consistent with chronic lung diseases. Per the Fire District Patient Care Report, it was noted that facility staff were unaware of R1s injuries. It was also noted that staff were informed of incident and the neglect of care. Per Executive Director, two staff members were both fired due to R1s incident. One staff member was fired for failure in job performance which resulted in a resident injury. It was reported that the staff watching R1 was laying on the couch on their cellphone and was not watching R1. The staff member denied seeing R1 fall, however, the same staff was able to explain how R1 fell. Staff reported that R1 was considered a fall risk. Based on the departments observations, interviews conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of regulations are being cited on the attached LIC9099D. Staff failed to seek medical attention for a resident. Staff not meeting resident needs. Per the Unusual Incident/Injury Report, R1 had a fall on 03/18/2022. The staff on shift that evening did not call 911 nor was R1's reasonable party notified of R1's fall. On 03/21/2022, it was noted in facility observation notes, staff noticed R1 had bruising from the fall on Saturday 03/18/2022. The staff did not call 911 or advise R1s family of the bruising. It was not until 03/22/2022, where R1s family member went to visit R1 and noticed bruising on R1s chest. R1s family member questioned staff as to where R1s bruise came from. Staff told R1s family member that R1 had a fall on 03/18/2022. On 03/22/2022, R1 was sent out to the hospital. Per medical records, it was determined that R1 had several areas of old vertebral compression fractures, old rib fractures, and findings consistent with chronic lung disease. Per the facility's fall and reporting procedures, if a resident has a fall (or assumed fall) the medical professional will assess the resident. If the medical professional is not available for an assessment the resident will be transported to the emergency room for further evaluation. Additionally, it states, the resident's first emergency contact will be notified of the need for transportation and evaluation. Based on records and documentation, staff failed to seek medical attention for the resident and therefore the resident’s needs were not met. Based on the departments observations, interviews conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of regulations are being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of Administrator on these forms acknowledges receipt of these documents.